CARROLL PARK HEALTHCARE
For profit - Individual
140 Beds
ENGAGE HEALTHCARE
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
Photo by Carroll Park Healthcare
Photo by Charles WBCStudio1
Photo by COOPERS CICHLID'S
1 / 5 photos
Last Inspection: November 2023
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Carroll Park Healthcare has received a Trust Grade of F, indicating significant concerns about the quality of care provided. This ranking places it at the bottom of all nursing homes in Maryland, meaning families have no local options that are rated better. While the facility is improving-reducing issues from 46 in 2023 to 10 in 2025-there are still critical areas of concern, including a high staffing turnover rate of 53%, which exceeds the state average and may affect the continuity of care. The facility has incurred $306,550 in fines, which is troubling and suggests ongoing compliance problems. Specific incidents include a failure to properly supervise residents who smoke, putting them at risk, and not providing CPR for a resident who needed it, which raises serious safety concerns.
- Trust Score
- F
- In Maryland
- #112/223
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $306,550 in fines. Lower than most Maryland facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Maryland. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 138 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 50%
Review needed
46 → 10 violations
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
2023: 46 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 53%
Near Maryland avg (46%)
Higher turnover may affect care consistency
Federal Fines: $306,550
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ENGAGE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 138 deficiencies on record
5 life-threatening 3 actual harm
May 2025
10 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on review of facility investigation and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of abuse. This was evident for 1 (MD0021...
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Based on review of facility investigation and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of abuse. This was evident for 1 (MD00216920) of 46 Facility Reported Incidents (FRIs) reviewed during an annual survey.
The findings include:
On 05/13/25 at 9:37 AM, review of facility documentation provided by the facility for MD00216920 revealed that in the early morning of 4/21/25, Resident #23 alleged Geriatric Nursing Assistant (Staff #36) was providing care to them, and Resident #23 told Staff #36 to stop and leave the room. Staff #36 continued to provide care despite the resident's request to stop.
On 05/13/25 at 9:39 AM, further review of MD00216920, revealed a written statement from Geriatric Nursing Assistant (Staff #37) stating she was present during the incident. Staff #37 indicated in their written statement that Resident #23 told Staff #36 to stop and get out, but that Staff #36 continued to provide care.
Further review of the facility documentation for MD00216920 at the same time revealed that Resident #23's Brief Interview for Mental Status (BIMS) was 15.
A Brief Interview for Mental Status (BIMS) is a tool used to screen and identify the cognitive condition of residents in a long-term care facility. The BIMS assessment uses a points system that ranges from 0 to 15 points. Scores from 13-15 indicate intact cognition.
On 05/14/25 at 07:39 AM, an interview with the Director of Nursing revealed that Staff #36 was put on the Do Not Rehire list because Resident #23 asked Staff #36 to stop providing care and she continued. The Director of Nursing further indicated that it was the expectation for staff to stop providing care if a resident indicated so.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of records and interviews, it was determined that the facility failed to implement its abuse policy. This was evident for 1 (Resident #61) of 5 residents reviewed for abuse allegations...
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Based on review of records and interviews, it was determined that the facility failed to implement its abuse policy. This was evident for 1 (Resident #61) of 5 residents reviewed for abuse allegations.
The findings include:
On 5/12/2025 at 10:56 AM, a review of the facility reported incident (MD00199361) was conducted. The review revealed an allegation of physical abuse towards Resident #61 on 11/9/2023 at 3:30 am. The alleged perpetrator was Staff #19, date of hire 8/22/23.
On 5/12/2025 at 11:26 AM, an interview with Resident #61 was conducted. When asked about the incident, Resident #61 stated that s/he called the police that day and that the police officer had told him/her that Staff #19 was working on another unit.
On 5/12/2025 at 1:26 PM, facility was asked to provide Staff #19's Timecard for 11/9/23.
On 5/13/2025 at 10:37 AM, the requested timecard was received. Review of this document indicated that Staff #19 clocked in at 11:10 pm on 11/8/23 and clocked out at 7:08 am on 11/9/23.
On 5/13/2025 at 10:47 AM, a brief interview with the Human Resource Director was conducted. S/he confirmed that Staff #19 continued to work his/her shift even after the allegations of abuse had been reported.
On 5/13/2025 at 11:24 AM, a review of the facility's abuse policy was conducted. According to the facility's policy, after an abuse allegation towards the residents, the alleged perpetrator is to be removed from the facility and away from other residents immediately.
On 5/13/2025 at 1:24 PM, facility administrator was made aware of concerns with the implementation of abuse policy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, the facility failed to report (1.) unusual occurrences, (2.) allegations of abuse in the required timeframe and (3.) allegations of abuse to a law enforcem...
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Based on record review and staff interviews, the facility failed to report (1.) unusual occurrences, (2.) allegations of abuse in the required timeframe and (3.) allegations of abuse to a law enforcement agency. This was evident for 3 (Resident #58, #59 and #90) out of 10 residents reviewed for facility reported incidents.
The findings include:
1.) On 5/09/25 at 10:11 AM, a review of Facility Reported Incident #MD00216808 was conducted. The incident report states that on 4/13/25. Resident #58 was found lethargic and difficult to be aroused, was placed on 3 liters of Oxygen via nasal canula, and given 2 doses of Narcan. Resident #58 was then sent out to the ER. Resident #58 tested negative for all medications except Methadone which s/he was taking at the time.
On 5/9/25 at 10:31 AM, a review of Resident #58's progress notes and the facilities investigation documentation was conducted. Based on progress notes the incident happened at 8:35 AM on 4/13/25. Upon further investigation the initial report was submitted to the OHCQ at 12:30 PM on 4/17/25. The final report was submitted on 4/22/25.
On 5/9/25 at 10:47 AM, an interview was conducted with the Director of Nursing and the administrator. When asked if they were aware that the incident was not reported in a timely manner. They stated that they were not aware that they were supposed to report incidents not involving abuse within 24 hours of the incident.
2.) On 5/9/25 at 7:30 AM, Facility Reported Incident #MD00206541 was reviewed. In the incident Resident #59 alleged Resident #67 sexually assaulted them. The incident documentation showed the incident was reported to the Office of Health Care Quality at 1:26 pm on 5/30/24. The incident was documented to have happened at 2:30 pm on 5/29/24.
On 5/13/25 at 9:39 AM, an interview with the Director of Nursing (DON). The DON confirmed the incident happened on 5/29/24 at 2:30 pm and was reported on 5/30/24 at 1:26 pm. This surveyor made the DON aware that all allegations of abuse must be reported to appropriate agencies within two hours.
3.) On 05/13/2025 at 9:03 AM, this surveyor reviewed the intake MD#00217660 and found out that the facility had reported an allegation of abuse to the state agency. In the self-report sent to the state agency, Resident #90 had reported that a nurse pulled his/her mask, yelled at him/her and took a video of him/her without consent.
On 05/13/2025 9:10 AM, this surveyor reviewed the facility reported investigation packet and discovered that Law enforcement agency was not notified of the alleged abuse incident.
On 05/13/2025 at 11:50 AM, in an interview with the Director of Nursing (DON), when she was asked who was notified whenever there was an abuse allegation, she stated that abuse allegations were reported to the State agency, the law enforcement agency, and the ombudsman. When asked whether the alleged abuse identified in intake #MD00217660 was reported to the law enforcement agency, she stated that she was not an employee at the facility at the time of the incident. She also informed the surveyor that if a police investigation number and related details were not found in the investigation packet, it meant the incident was not reported. The surveyor informed her that no police investigation number and related detail was included in the packet. She reviewed the investigation packets and confirmed that a police investigation number and related details were not included and added that the law enforcement agency was not notified.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, it was determined that facility staff failed to 1) ensure the resident's n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, it was determined that facility staff failed to 1) ensure the resident's nutritional status was accurately assessed, documented, and up to date in accordance with healthcare standard of care guidelines and 2) provide services that meet professional standards by not following written physician orders. This deficient practice was evident for 2 residents (#13 and #67) reviewed during the annual survey.
Based on record reviews, observations, and interviews, it was determined that facility failed to provide services that meet professional standards by not following written physician orders. This was found to be evident for Resident #67 during the annual survey.
The findings include:
During the initial tour of residents on the 4th floor on 05/07/25 at 7:48 AM, the surveyor entered room [ROOM NUMBER] and observed Resident #13 sleeping in bed. The resident appeared malnourished with signs of cachexia (wasting syndrome). Review of the resident's electronic medical records (EMR) revealed the resident has a diagnosis of quadriplegic and is completely dependent on facility staff for all activities of daily living.
On 05/07/25 at 10:48 AM, review of complaint intake MD00200515 revealed that the resident's family had concerns regarding the resident's care and nutritional status.
During an interview with Resident #13's family on 05/08/25 at 4:28 PM, they stated the resident lost a lot of weight and mentioned how staff often fail to ensure the resident received meals.
A review of the EMR on 05/08/25 at 1:06 PM, indicates that quarterly nutritional assessments were conducted by the Registered Dietitian (RD) # 18 on 7/5/24, 01/16/25, and 04/18/25. It is noted that the resident is meeting more than 75% of estimated calories and protein needs based on the last documented weight. Review of the resident's weight summary indicates that the last documented weight was on 02/29/24.
The residents' orders include a regular double portion meal and a liquid protein supplement. A review of meal intake records for June 2024, July 2024, December 2024, and January 2025 shows that Resident #13 consumed on average 50% of meals provided for breakfast, lunch, and dinner.
On 05/09/25 at 3:05 PM, during an interview, with RD #18, he explained that nutritional assessments are conducted at the time of admission, quarterly, annually, and when there are significant changes in the resident's condition. The surveyor asked why some assessment dates were missing for Resident #13. The RD #18 states that an assessed was conducted between July 2024 and January 2025, however, it was not documented resident's EMR. Instead, the assessment was documented in a Google Drive file on the RD's computer.
The surveyor inquired about the RD #18's documentation indicating that the resident was meeting more than 75% of estimated calories and protein needs based on the last recorded weight, although the resident had not been reweighed. The RD #18 explained that the assessment was based on the resident being ordered a double portion meal. When asked if he possibly overestimate the resident's calorie and protein intake per meal, the dietitian was unable to confirm if overestimation had occurred. He further explained that the resident nutritional supplements were changed to ensure adequate protein intake and to address both malnutrition and wound healing. The surveyor noted that the resident's medical record did not include documentation to indicate why the supplement was changed.
The Administrator was present during the interview with the registered dietitian.On 5/7/2025 at 10:37 AM, during the initial screening of Resident #67, left hand contractures were observed by the surveyor. No brace or splint was observed on the resident's left hand.
Further review of the resident's medical records on 5/8/2025 at 12:00 PM revealed an order initiated on 10/2/2024 that stated the resident is to wear left palm grip for contracture management and only to be removed during daily hand hygiene. No additional information was able to be found in the resident's chart documenting use of palm grip, contradictions to usage, or resident refusal by the surveyor.
Additional observations of Resident #67 on 5/8/2025 at 1:00 PM and on 5/9/2025 at 8:17 AM revealed that the resident was not wearing a palm grip in their left hand.
On 5/9/2025 at 8:38 AM, Resident #67 was observed by surveyor and Licensed Practical Nurse (LPN) #15, LPN #15 confirmed resident was not receiving hand hygiene at the time and was not using a left palm grip. LPN #15 was also observed by the surveyor to not be able to find documentation of palm grip usage in resident's electronic health record. LPN #15 stated to the surveyor that they would contact the unit manager to make them aware.
Resident #67 was observed to have palm grip in left hand by surveyor on 5/9/2025 at 9:23 AM. The Director of Nursing was made aware of surveyor concerns at 9:42 AM, no additional information was provided by facility staff regarding Resident #67 not using a palm grip during previous observations by surveyor.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interviews, observations and record reviews, it was determined that facility staff failed to ensure that wound care treatment was completed as ordered by the physician. This deficient practic...
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Based on interviews, observations and record reviews, it was determined that facility staff failed to ensure that wound care treatment was completed as ordered by the physician. This deficient practice was evident for 1 (#13) of 5 residents reviewed for physician orders during the annual survey.
The findings include:
During an interview with Resident #13 on 5/9/25 at 12:30 PM, the resident reports that wound dressing changes are scheduled for every Tuesday, Thursday, and Saturday, however, the dressing change for Thursday 5/8/25 was not done. An observation of Resident #13's left arm revealed that the last dressing change occurred on Tuesday 5/6/25 which is outside the ordered treatment schedule.
On 05/09/25 at 1:30 PM, during a record review for Resident #13's treatment administration records (TAR) reveal an order to cleanse and dress wound located on the left forearm every evening shift every other day. Further review of the TAR reviewed that that last recorded wound dressing change was documented on 05/06/25. There was no documentation indicating why the change was not completed on 05/08/25.
On 05/12/25 at 09:12 AM, during an interview with the Director of Nursing (DON), she states that staff are expected to document the status of all wound dressing changes including when a dressing change is not completed. The surveyor informed the DON of the undocumented wound care and reviewed the missing documentation in the medical records. The DON states that she will address documentation expectations with the staff.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that facility staff failed to ensure that geriatric nursing assi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that facility staff failed to ensure that geriatric nursing assistant (GNA) maintained an active certification. This deficient practice was evident in 1 out of 7 GNA employee files reviewed during the annual survey.
The findings include:
On [DATE] at 2:30 PM, during an interview with the Administrator, the surveyor requested the employment file for GNA #40.
On [DATE] at 9:30 AM, during an interview with the Human Resource Director #10, the surveyor again requested for the employee file for GNA #40. During a review of the employee file, the surveyor identified that the GNA's certification had expired on [DATE].
On [DATE] at 2:30 PM, the surveyor informed the Administrator that GNA #40's certification expired. The Administrator stated that the employee was not working that day and would follow up with the HR Director #10 regarding the status of the GNA's license.
On [DATE] at 7:53 AM, the Administrator confirmed that the GNA's certification is expired.
On [DATE] at 7:58 AM, during an interview with HR Director #10, the surveyor inquired about the process for ensuring staff certifications and licenses remain current and active. The HR Director #10 states that at the time of hire, she notates certification and licenses on a spreadsheet on the computer and reviews the expiration dates monthly. When asked about GNA #40's expired certification, the HR Director #10 acknowledged that it was an oversight.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, it was determined that facility staff failed to ensure that annual performance reviews were conducted for all geriatric nursing assistant (GNA). This deficient ...
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Based on record reviews and interviews, it was determined that facility staff failed to ensure that annual performance reviews were conducted for all geriatric nursing assistant (GNA). This deficient practice was evident in 7 out of 7 GNA's annual performance reviewed during the annual survey.
The findings include:
On 05/08/25 at 10:42AM, the surveyor requested the complete GNA employee files for GNA's, 23, #24, #25, #26, #27, and #28. The surveyor informed the Human Resource (HR) Director #10 that each file should also include the employee's annual performance review.
A review of the employee files on 05/09/25 at 7:58 AM for GNA's #23, #24, #25, #26, #27, and #28 revealed that the requested annual performance review were not included in the submitted files.
On 05/09/25 at 2:30 PM, the surveyor informed the Administrator of the requested GNA employee files and the missing annual performance reviews. The Administrator stated that the HR Director #10 would locate the requested files. The surveyor requested an additional GNA employee file for GNA # 40.
On 05/12/25 at 9:30 AM, during an interview with the HR Director #10, she explained that employee appraisal reviews are conducted annually. The surveyor made a second request for annual performance reviews for GNA's, #23, #24, #25, #26, #27, #28 and #40. The HR Director stated that she would locate the files.
On 05/14/25 at 8:02 AM, during an interview, the Director of Nursing (DON) explained that she completes GNA annual performance reviews upon receiving a list of upcoming review due dates. She further stated that the HR Director #10 will verbally notify her if any reviews are incomplete by the deadline date. The DON notes that the GNA annual appraisal includes goals, areas of strength, areas of improvement, future goals and expectations.
The surveyor informed both the Administrator and the DON that the GNA employees' files, including annual performance reviews, were requested on 05/08/25. As of 05/14/25, the requested files had not been provided. Both the Administrator and DON acknowledged that the surveyor would no longer request the files.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it was determined the facility staff documented inaccurate data in the resident's chart. This was evident in 1 out of 6 resident's reviewed in the recertifi...
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Based on record review and staff interview, it was determined the facility staff documented inaccurate data in the resident's chart. This was evident in 1 out of 6 resident's reviewed in the recertification survey.
The findings include:
On 5/13/25 at 8:02 AM, a review of Complaints #MD00199200 and #MD00200378 was conducted. Both complaints alleged the facility provided a lack of Quality of Care leading to Resident #94's transfer to hospital requiring critical care.
On 5/13/25 at 8:35 AM, a review of Resident #94's records was conducted. A progress note on 11/6/23 at 8:50 AM indicated the resident was going to be sent out to the ER at the family's request. A progress note on 11/6/23 at 9:36 PM indicated that the resident was out of the facility. Review of the resident's blood pressure indicated the resident's blood pressure on 11/6/2023 at 8:31 AM was documented as 85/63 mmHg. On 11/7/23 at 5:06 AM, the resident's blood pressure was documented as 129/75 mmHg.
On 5/13/25 at 10:23 AM, an interview with the Director of Nursing (DON) was conducted. When asked about how Resident 94's blood pressure was documented after discharge date , The DON stated they did not know how or why that blood pressure was documented after the resident was discharged . When asked what the expectation was for documentation after discharge, the DON stated no documentation of vital signs should be done after resident has been discharged .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it was determined that the facility failed to maintain records of investigation documentation. This was evident for 2 (Resident #38 and #53) out of 10 resid...
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Based on record review and staff interview, it was determined that the facility failed to maintain records of investigation documentation. This was evident for 2 (Resident #38 and #53) out of 10 residents reviewed for facility reported incidents.
The findings include
1.) On 5/7/25 at 2:19 PM, Facility Reported Incident #MD00206207 was reviewed. It was reported that Resident #53 alleged that $70 was stolen from their possession.
On 5/8/25 at 1:00 PM, the facilities investigation of Resident #53's money was reviewed. The investigation file contained only the initial and follow-up self-reports that were submitted to the Office of Health Care Quality.
On 5/8/25 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). When asked if the investigation file provided was the complete investigation for Resident #53's incident, the DON stated, Yes, that is all we have. When asked if they were able to provide any statements, interviews, in-services, or education from this investigation, the DON stated that what was in the file is all they had. The surveyor requested Resident #53's inventory lists. The facility was able provide the document.
2.) On 05/09/2025 at 7:45 AM, a review of facility reported incident #MD00207676 was conducted. The incident report revealed that Resident #38 was found to be high, drowsy, and sleeping in the walkway. One of the aides reported that this behavior was unusual for this resident. He/She would normally return to his/her bedroom to sleep if needed.
On 05/07/2025 at 10:00 AM, another surveyor requested for the facilities investigations for all facility reported incidents from Nursing Home Administrator (NHA).
On 05/09/25 at 01:43 PM, this surveyor requested the facilities investigation relating to Resident #38 from the Director of Nursing (DON) and she stated that the NHA was still looking for it.
On 05/09/25 at 02:02 PM, in an interview with the NHA, when she was asked for the investigation packet for the intake MD#00207676, she informed the surveyor that the investigation packet could not be found, and that the facility does not have it.
On 05/09/2025 at 2:41 PM when the DON and the NHA were asked how long a document should be kept, the DON stated that for 5 years and when the concern about the missing investigations were discussed with them, they both acknowledged that the document should have been made available upon request and kept for 5 years.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observations and record review, it was determined the facility failed to maintain an effective pest control program. This had the potential to affect all residents.
The findings include:
On ...
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Based on observations and record review, it was determined the facility failed to maintain an effective pest control program. This had the potential to affect all residents.
The findings include:
On 5/12/25 at 6:25 AM, An observation was made in the facility lobby, hallway, and conference room. 1 large black and brown insect was observed in the conference room, 1 large black and brown insect was observed in the hallway of the 1st floor, 1 large black and brown insect was observed on the hallway of the 4th floor, and 1 large black and brown insect was observed in the Lobby.
On 5/12/25 at 7:00 AM, the facilities pest control logs were reviewed. Based on log documentation, multiple roach sighting. 12/5/24- 12/11/24 and treated on 12/13/24. Multiple roach sightings were reported on 12/15/24 through 12/20/24 and treated on 12/27/24. A roach sighting was reported on 12/30/24 and treated on 1/10/25.
On 5/12/25 07:20 AM, a review of Facility Reported Incident #MD00204936 from 4/23/24 was conducted. A report was made to the Office of Health Care Quality of a Bedbug sighting in the Lobby on 4/15/24.
On 5/12/25 at 7:25 AM, the Director of Nursing was made aware of the insect sightings on 5/12/25.
On 5/12/25 at 7:38 AM, a review of the facility's investigation of Bed bugs sighted in lobby on 4/15/24 was conducted. The facility's pest control company came to the facility on 4/16/24 to treat the facility for bed bugs. The pest control technician did not see any bed bugs at the time of report. The technician completed an initial treatment for bed bugs including products of Cimexa, Crossfire, and Temprid. Per the technician's report product was applied with sprayer to cracks and crevice of beds, bed frames, box springs, headboards, dressers, couches, chairs, molding & trim, carpet seaming, smoke detectors, electrical switches & sockets, curtain & shade brackets, & closet shelving.
On 5/12/25 at 10:15 AM, an interview was conducted with the Maintenance Director (Staff #3). When asked if they were aware of a current insect problem, Staff #3 stated they were aware of waterbug sightings and stated that the pest control company had been treating the facility for them. Staff #3 stated that they were not aware of this being a current issue. This surveyor made Staff #3 aware of the sightings made on 5/12/25.
On 5/14/25 at 11:16 AM, a review of Complaint #MD00201889 was conducted. The complaint stated there was evidence of mice in a resident's room on the 4th floor in December 2023.
On 5/14/25 at 11:20 AM, a review of the pest control log of December 2023 was conducted. 24 mice sightings were documented in the month of December. In the pest control log, there was documented mice sightings throughout the 4th floor on 12/5/23.
Nov 2023
46 deficiencies
4 IJ (2 affecting multiple)
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and medical record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and medical record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. This was evident for 1 resident (# 266) out of 1 reviewed for CPR initiation.
The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 3:00 PM on [DATE]. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 7:55 P.M. on [DATE].
The findings include:
According to the American Heart Association (AHA) Cardiopulmonary Resuscitation (CPR) is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple the chances of survival after cardiac arrest.
A Code Status means the type of emergent treatment a person would or would not receive if their heart or breathing were to stop.
Full code means that if a person's heart stops beating and/or they stop breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR.
During a random observation conducted on [DATE] at approximately 6:00 AM, the surveyors observed Licensed Practical Nurse (LPN) #6 assigned to Resident #266 entered the resident's room, quickly exited, and returned to the nursing station.
The surveyors observed LPN #6 search through papers on the nursing station desk. The LPN asked Geriatric Nursing Assistant (GNA) #85 who sat at the nursing desk if she knew the 3rd floor nursing station phone number, and the GNA replied No.
At approximately 6:11 AM, LPN #6 located the phone number and requested for Registered Nurse (RN) #25 to come to the 4th floor, however, she did not state why she requested the RN to come to the 4th floor nursing station.
At approximately 6:14 AM, RN #25 arrived at the 4th floor nursing unit. LPN #6 advised RN #25 that Resident #266 had died and that she was only an LPN and could not perform the assessment. The RN #25 responded, Okay, I need to go get my stethoscope on the 3rd floor nursing unit.
A Do Not Resuscitate (DNR) order is a legal document that means a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops.
RN #25 returned to the 4th floor nursing unit at approximately 6:18 AM. The surveyor observed the RN pull a resident's physical chart at the nurses' station and stated the resident had a code status of Do Not Resuscitate (DNR). The surveyors observed the RN perform an assessment on resident #266 at which time the RN stated the resident was deceased .
On [DATE] at 08:13 AM, this surveyor reviewed Resident #266's physical chart and located a Maryland Order for Life Sustaining Treatment (MOLST) form dated [DATE] with the direction to perform CPR.
During an interview conducted on [DATE] at 08:34 AM, the surveyors asked LPN #6 what her first steps were when she identified Resident #266 was unresponsive. The LPN stated I saw that the resident was not breathing, I attempted to take the pulse and found the resident did not have a pulse and was cold. I then attempted to call the Director of Nursing (DON) and Administrator but was unsuccessful. I then called RN #25 on the 3rd floor nursing unit to come to the 4th floor.
The LPN further stated she learned Resident #266's code status was CPR and not DNR when the Emergency Medical Services (EMS) arrived.
On [DATE] at approximately 9:00 AM, the surveyors requested the facility's policy and procedures for calling a code and CPR. The surveyor was provided with a Mock Code evaluation checklist and a CPR policy.
The Mock Code Evaluation Checklist stated - First person arrives on scene assess airway- breathing noted to be absent or gasping with a pulse within 10 seconds, if no pulse & abnormal breathing proceed with the steps: call out for other staff to help, command given to call 911 and call a code, code on overhead page, other staff arrive with the crash cart, command given for someone to meet the EMS and direct to the resident's location, perform hand hygiene, PPE donned, resident placed in a supine on firm surface (backboard or floor), if on an air filled mattress; deflated mattress for compressions.
The Mock Code Evaluation Checklist continues in its guide providing detailed procedures for performing chest compressions on a resident who does not have a pulse and the use of a handheld resuscitation bag.
The CPR policy stated It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation.
The Policy explanation and Compliance Guidelines included:
1.
The facility will follow current American Heart Association (AHA) guidelines regarding CPR.
2.
If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to
the arrival of emergency medical services:
2a. In accordance with the resident's advance directives, or
2b. In the absence of an advanced directive or a Do Not Resuscitate order; and
2c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity,
decapitation, transection, or decomposition).
3. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in -person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable.
An automated external defibrillator (AED) is a medical device designed to analyze the heart rhythm and deliver an electric shock to victims of ventricular fibrillation to restore the heart rhythm to normal.
During an interview conducted on [DATE] at 10:39 AM, the Regional Director of Clinical Operations stated the facility staff expectations for when a resident is found unresponsive are the first responder will call a code while remaining with the resident, the code cart and physical chart is taken to the area where the resident was found unresponsive. CPR would be initiated if directed on the MOLST form. If the resident is a full code the staff would use an AED until EMS arrives and takes over. The event is documented with a detailed timeline.
The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 7:55 P.M. on [DATE].
The plan included an audit of all licensed nurses, agency licensed nurses, and newly hired licensed nurses to evaluate their knowledge of correctly identifying the accurate code status for the correct resident and providing education accordingly. An audit of all licensed nurses, agency licensed nurses, and newly hired licensed nurses was conducted to evaluate the knowledge of what to do when a resident is found unresponsive, calling a code, and conducting a code. Education was provided based on the findings of the audit. A mock code was conducted on all shifts with all nursing staff, the findings were evaluated, and education was provided accordingly.
The plan also included future mock codes that will be conducted weekly for 4 weeks and then monthly for 3 months. The results of the mock codes will be submitted to the Quality Assurance Improvement Plan (QAPI) Committee.
The survey team confirmed the facility met the compliance date of their action plan and the Immediate Jeopardy was abated on [DATE].
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0740
(Tag F0740)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy records, review of a facility's program description, and interviews with staf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy records, review of a facility's program description, and interviews with staff it was determined that the facility: (1) failed to timely implement physician instructions and orders related to SUD treatment, and (2) failed to effectively plan care for residents with Substance Abuse Disorder (SUD) and (3) failed to initiate a Substance Use Disorder care plan for Residents identified with Substance Use Disorders. This was evident for 5 (Residents #147, #90, #101, #141 & #154) of 18 residents reviewed for Substance Use Disorder during survey. These failures contributed to resident overdoses and placed residents at increased risk for serious harm and possible death.
The findings include:
1. Suboxone: is part of a family of medications used in Medication Assisted Treatment (MAT).
Medication Assisted Treatment (MAT): is an addiction recovery treatment plan that includes medications designed to treat opioid use disorders.
Substance Use Disorder: is a treatable mental disorder that affects a person's brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications.
Narcan: A medication given to help reverse an opioid overdose.
On [DATE] at 11:38 AM, the surveyor reviewed Resident #147's medical record. The record revealed a progress note written on [DATE] by the Wellness Program Director, Staff #29. The note stated Staff #29 visited with Resident #147 and introduced the Wellness Pathway Program to the resident. After the introduction, Resident #147 discussed his/her history of substance abuse with Staff #29. Resident #147 reported having cravings and requested to be prescribed Suboxone stating, this has worked in the past. Staff #29 wrote in her note she would make the physician aware of the request.
On [DATE] at 10:53 AM, the surveyor interviewed Staff #29. During this interview Staff #29 stated she was an advocate for residents with Substance Use Disorders (SUD). She further explained that she is made aware by the administrator or nursing staff when a Resident with a history of SUD is being admitted to the facility. Staff #29 stated she introduced herself to the Residents and introduced them to the program. She gets a history as well as assists Residents with identifying triggers that may cause them to relapse. Staff #29 also stated she relays medication needs with providers and communicates a need for a psychological evaluation if needed. She stated she helps in developing the care plans for SUD Residents. Staff #29 stated that nursing is responsible for assessing, monitoring, and implementing interventions to prevent relapse.
On [DATE] at 6:26 AM, the surveyor reviewed the Wellness Program overview. The program description documents evidence-based services to support a life of recovery while at a skilled nursing/rehabilitation center. It further indicated that the Wellness Director (WD); develops, plans, organizes, evaluates, and directs the overall operation and therapeutic aspects of the Wellness Program.
On [DATE] at 11:38 AM, the surveyor review of the progress notes written in Resident #147's medical record on [DATE] by a physiatrist (a doctor who specializes in physical medicine and rehabilitation) Staff #78. Under medication changes, Staff #78 wrote, Resident #147 stated he/she was previously on Suboxone, but the dose will have to be verified and restarted. Staff #78 added that Resident #147 reported his/her pain was not controlled by pain medications.
A progress note written on [DATE] at 2:12 PM, by Social Service Staff #83 documented Resident #147 was reporting terrible sleep due to anxiety attacks and trouble concentrating.
In a [DATE] progress note, Staff #78 recommended to verify Suboxone dosing and restart medications. This note concluded; thank you for allowing me to participate in the care of your patient. I will continue to follow. No evidence was found in Resident #147's medical record that the verification was obtained after the prior [DATE] note written with these same instructions.
Further review of the medical record revealed that Resident #147 suffered a medical emergency on [DATE] at 2 PM. Resident #147 was found unresponsive and two doses of Narcan (an emergency treatment for a narcotic overdose) was administered. Resident #147 responded to the Narcan and requested to be transferred to the hospital. No evidence was found that the dose for Suboxone was clarified or that he/she had ever started on Suboxone after it was first recommended two weeks prior to the [DATE] clinical emergency. Further review of the medical record on [DATE] at 1:50 PM, revealed that Resident #147 returned to the facility on [DATE]. With the discharge paperwork, the hospital provided an order for Buprenorphine HCL 8mg Sublingual tablet. (Buprenorphine is the active ingredient in Suboxone).
The surveyor reviewed the orders written for Resident #147 on [DATE] at 1:58 PM. The review revealed that on [DATE] an order was written for Buprenorphine Hydrochloride HCL sublingual 8 mg three times a day for smoking cessation.
On [DATE] at 11:45AM, the surveyor reviewed a progress note written by Physician Assistant (PA) Staff #56 on [DATE] at 3:32 PM. In this note Staff #56 indicated that Resident #147 continued on Suboxone 3 times a day and had no signs or symptoms of withdrawal.
On [DATE] at 11:51 AM, the Surveyor review of the Medication Administration Record (MAR) for Resident #147. The review revealed the documentation was incomplete and did not provide evidence the Buprenorphine was administered as directed. The documentation indicated that on 12 occasions from [DATE] through [DATE] the administration was coded, see progress note and on 3 occasions during that same time period the administration documentation was blank for administration on Buprenorphine.
On [DATE] at 10:35 AM, the surveyor reviewed medication administration progress notes. On [DATE] at 5:57 AM, the MAR comment was, pharmacy to deliver, and on [DATE] at 6:31 AM, the MAR comment was, pharmacy to dispense med (medication).
Further review of the clinical record revealed a note written on [DATE] at 2:46 PM, that stated Resident #147 was responsive only to a sternal rub and Narcan was administered.
On [DATE] a note written at 3:25 PM, stated Resident #147 appeared to be sluggish. The note further indicated that the physician was aware and orders were received including a urine toxicology screen.
On [DATE] at 9:10 AM, the surveyor conducted a phone interview with the Manager from the pharmacy the facility utilizes, Staff #80. During this interview Staff #80 stated the pharmacy received the order for Resident #147's Buprenorphine on [DATE] at 9:45 AM, however, it was sent back asking the provider for more clarification. At this point, Staff #80 asked a Staff Pharmacist, Staff #81 to join the phone conversation. Staff #81 stated a clarification was re-sent and dated [DATE] on the form, however the fax had a time stamp from the facility that indicated the order was sent on [DATE] at 7:48 AM from the facility and the pharmacy received the clarification order on [DATE] at 7:51 AM. Staff #81 reviewed the dispensing records for Buprenorphine to the facility for Resident #147. The review revealed that only a portion of the dose was sent to the facility on [DATE] and signed as received at 5:30 PM. The complete dose was not sent until [DATE] at 1:54 AM.
On [DATE] 6:37 AM, the surveyor reviewed Resident #147's care plan. On [DATE] a care plan was created stating Resident #147 was receiving Medicated Assisted Treatment (MAT) for Substance Use Disorder (SUD) and was at risk for an overdose. This care plan was created 5 months after Resident #147's first overdose and the one intervention stated, to educate Resident #147 on risks related to substance abuse. No individualized interventions were planned for staff to monitor for triggers or withdrawal symptoms to prevent potential relapse.
2) On [DATE] 8:39 AM, the surveyor reviewed Resident #90's medical record the review revealed Resident #90 had a history of Substance Use Disorder. The review further revealed that Wellness Program Director Staff #29 wrote a progress note on [DATE] shortly after introducing the Wellness Pathways Program to Resident #90. In the note, Resident # 90 indicated he/she was currently taking Suboxone and was able to maintain abstinence with Medicated Assistance Treatment (MAT). However, no order was written for Suboxone for Resident #90 at this time. Staff #29 documented she would follow up as needed.
On [DATE] at 5:22 AM, the surveyor reviewed Resident #90's care plan. A care plan was initiated on [DATE] by Staff #29. On [DATE] Staff #29 updated the care plan and initiated the following interventions: Monitor and report any unusual behavior to the physician; Wellness coordinator to follow-up with treatment; Follow up with social worker; Psychiatry consult for substance abuse; and Continue with medications for opioid use disorder. The plan did not include any interventions for monitoring for individualized triggers or signs of withdrawal, to reduce risk for relapse.
Further review revealed a [DATE] progress note. That documented Resident #90 was found unresponsive in another Resident's room in a suspected overdose. Narcan was given twice, and Resident #90 became responsive after.
On [DATE] at 1:15 PM, Wellness Program Director Staff #29 wrote a progress note after visiting with Resident #90. In this progress note, Staff #29 documented that Resident #90 reported struggling with cravings and reported when on Suboxone in the past he/she had less cravings and urges to use. Staff #29 stated she would follow up with the medical team about MAT.
On [DATE] a progress note documented that Resident #90 was found unresponsive and after 3 doses of Narcan Resident #90 became responsive. Resident #90 was placed on 1:1 monitoring, and psychiatry was ordered to evaluate for possible transfer to the hospital for an evaluation.
On [DATE] at 9:12 AM, the surveyor reviewed the orders written for Resident # 90. The review revealed Suboxone was first ordered on [DATE] by Physician Staff #50.
On [DATE] at 9:20 AM, the surveyor reviewed a progress note written by Physician Assistant PA Staff #56 on [DATE] in Resident #90's medical record. In the assessment and plan section, Staff #56 documented the plan after the overdose for Resident #90 was to continue to assist with activities as needed and would evaluate for Suboxone. The note concluded; the plan of care was discussed with Medical Director Staff #19.
On [DATE] at 11:35 AM, the surveyor reviewed Resident #90's September Medication Administration Record (MAR). The review revealed that Suboxone was documented as given on [DATE] in the am and given twice a day [DATE]-[DATE].
Further review of the care plan initiated on [DATE] revealed that the care plan stated Resident #90 was receiving Medication Assisted Treatment for Substance Use disorder. The care plan was updated on [DATE] by Unit Manager Staff #3, who stated Resident #90 was receiving MAT for Substance Use Disorder and was found unresponsive. However, after reviewing Resident #90's medical record he/she did not receive MAT until [DATE]th 2023, after the second overdose.
The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the
Federal definition of Immediate Jeopardy and the facility was verbally notified of this
determination on [DATE] at 10:00 AM. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by OHCQ at 6:50 PM after 4 initial plans were submitted at 1:19 PM, 4:22 PM, 6:15 PM, and 6:37 PM.
The plan included: Education for Staff #29 on effective management for Residents with SUD, to include communication with physician and nurses on Resident changes such as withdrawal symptoms or craving for substance use. Education was provided for Staff #78 to include, communication on the use of MAT for Residents who are noted as craving for substance use as well as communication with the nursing team if there is a recommendation for residents with substance use. The Wellness Director completed a house wide audit of current Residents with Substance Use Disorder to evaluate if any other Residents are reporting carvings for substance use or any symptoms of withdrawal to ensure MAT is ordered according to their person centered plan of care.
The facility's plan for removal also included the following: Education on the use of a screening tool, used on admission, to identify any residents with a history of substance use disorder and evaluate if they are interested in receiving treatment. Nursing will then update the care plan accordingly. The Director of Nursing will educate the Unit Managers on the effective management of residents with Substance Use Disorders. This will include using the screening tool on admission; Ensure Residents with SUD are ordered appropriate medications on admission; Communicate any changes noted with SUD Residents with the Wellness Director and physicians to ensure MAT is implemented if indicated; Ensure if a MAT medications is unavailable the physician is notified and symptoms of withdrawal and triggered are monitored, if needed obtain a order for MAT; Ensure comprehensive care plan are completed to include resident's history of SUD, withdrawal symptoms, triggers, relapse, and treatments.
The Unit Manger will then educate the licensed nurses.
The DON will complete random questionnaires audits for physician, nursing team and wellness services to validate the team is communicating changes. The Medical Director will complete random audits of the Residents receiving MAT to validate effective MAT treatment. The DON will complete random medical record audits for those SUD residents identified on MAT where the MAT was not available. The audit will evaluate if assessments are being made to monitor for signs of withdrawal and an order effective treatment is in place to prevent drug overdose. The audits will be done weekly for four weeks then monthly for three months and the findings will be reported to the Quality Assurance/Performance Improvement Committee (QAPI) for review.
After determination of Immediate Jeopardy concerns, the Immediate Jeopardy was removed on [DATE] after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents.
3) Medical record review for Resident #101 on [DATE] 7:23 PM, revealed that Buprenorphine HCl-Naloxone HCl (Suboxone) Sublingual (applied under the tongue) 8-2 Milligrams, 2 times daily, for SUD, was ordered on [DATE] at 9:00 PM. The order was written at 9 PM with the first administration documented as given on [DATE].
Medical record review on [DATE] at 7:41 AM, revealed that Staff #29 created a new care plan for Resident #101 for Medication Assisted Treatment (MAT) for Substance Use Disorder (SUD) related to opioid use disorder on [DATE].
Medical record review on [DATE] 7:31 AM, revealed a potential overdose event on [DATE]. In an initial progress note dated [DATE], Staff #29 documented seeing Resident #101 for a change in condition related to substance abuse. Staff #29 indicated that Resident #101 had been found on the floor after suspected use on [DATE]. Staff #29 further documented that Resident #101 reported struggling with cravings. Staff #29 concluded the progress note indicating a plan to follow up with the medical team.
Medical record review revealed inconsistent documentation entered by Staff #56 on [DATE]. Although the [DATE] event was documented in the medical record, Staff #56 inconsistently documented on [DATE] that Resident #101 was on Buprenorphine, had experienced no changes in mental status, and that no evidence of withdrawal was evident. Staff #56 documented that the plan of care was discussed with Medical Director Staff #19.
Additional medical record review on [DATE], revealed that the [DATE] MAT care plan was revised on [DATE]. The revisions included documenting the new [DATE] change in condition associated with substance use and interventions were added including to monitor and report any unusual behaviors to the doctor, for the wellness coordinator to follow-up with treatment, for the social worker to follow up, for psychiatry consult related to substance abuse, and to continue Medicated Assisted Treatment. However, no interventions were initiated in the plan to monitor for individualized triggers and/or withdraw symptoms.
Medical record review revealed a second potential overdose event for Resident #101 on [DATE]. A nursing note by LPN Staff #24 on this date indicated that Narcan HCL nasal liquid 0.1 milligram was given at 8:45 AM for suspected overdose. In a later note at 2:50 PM on the same date, Staff #29 documented that she met with Resident #101 due to substance use. Again Resident #101 reported to Staff #29 experiencing carvings and again Staff #29 documented the plan to update the medical team.
After the second event, the MAT care plan was still not revised to ensure that staff would begin to monitor Resident #101 for individualized triggers and/or withdrawal symptoms.
4. Review of Resident #149's closed medical record on [DATE] revealed Resident #149 most recent admission to the facility was on [DATE] with diagnoses that included anxiety, depression, bipolar disorder, alcoholic cirrhosis of the liver, heart failure, chronic kidney disease, insomnia, and psychoactive substance dependance. Resident #149 was receiving the following medications: Aripiprazole, bupropion HCL, Lexapro, Methadone HCL, Risperdal, Trazodone, Lasix, Xanax, Gabapentin, and oxycodone.
Review of intake MD00186021 on [DATE] revealed an investigation that Resident #149 was observed to be drowsy, lethargic, and unresponsive with a bottle of diazepam found next to Resident #149 on [DATE] at 10:15 AM. The facility staff identified Resident #149 as having an overdose and administered 2 doses of Narcan. Resident #149 was observed to become more alert and was transferred to the emergency room. After a few hours, Resident #149 returned to the facility and was educated on the risks and dangers of ingesting medications not prescribed by the facility physician. Resident was issued and signed a behavior contract on [DATE]. Resident #149 explained to the facility staff that he/she brought the medications from home when he/she went on a leave of absence. The facility investigation indicated that the facility staff were educated on the importance of rounding to identify residents with illicit drug use, Resident #149 was educated on the risk and dangers of ingesting medications not prescribed by a facility physician, and a Behavioral Contract was presented to the resident.
Review of facility reported incident MD00188974 on [DATE] 23 revealed an investigation that on [DATE] Resident #149 was observed with an unknown pill and ingested the pill in front of a staff member. Resident #149 was also observed with agitation, slurred speech, and was having difficulty forming thoughts into sentences. Another bottle of pills was discovered with Resident #149 who stated that a family member gave them to him/her. Resident #149 was sent to the emergency room. The facility determined that Resident #149 had another overdose on illicit medications.
Further reviews of the closed medical record failed to reveal the facility staff had implemented a care plan for Resident #149's diagnosis of psychoactive substance dependance.
5. Review of Resident #154's closed medical record on [DATE] revealed Resident #154's most recent admission to the facility in [DATE].
The State Survey Agency (SA) received complainant allegations (Intake MD00194736) indicating that Resident #154 suffered an overdose and died on [DATE]. A review of facility reported incident MD00189238 on [DATE] revealed information that Resident #154 was found unresponsive on [DATE] at 1:40 AM. Staff administered Narcan twice, initiated CPR, and called 911. EMS personnel arrived and continued to perform CPR. Resident #154 was shortly pronounced dead. The facility investigation listed a summary of events that indicated no evidence to support active drug use. After the incident, staff were educated on the importance of reporting any suspicion of illicit substance use.
Closed medical record review on [DATE], revealed that Resident #154 suffered a drug overdose event on [DATE]. Record documentation indicated that on this date at 8:30 PM, Resident #154 was observed by a staff member unresponsive and lying on the floor. The staff administered 2 doses of Narcan nasally. Resident #154 was sent to the emergency room. Per the hospital documentation, Resident #154 was diagnosed with an opioid overdose in the emergency room.
Additional review of the closed record revealed that on [DATE] Resident #154 suffered another drug overdose event. On this date at 3:27 PM, staff observed Resident #154 to be lethargic with little to no response to verbal or tactile stimuli, speech that was described as sluggish, and s/he could not sit straight in his/her wheelchair. With consent, a toxicology test was conducted which later returned (returned on 02/21).
The reported event of [DATE] was therefore the third overdose event for Resident #154. Nonetheless, no care plan was ever opened providing staff direction on what and how to manage Resident #154's needs related to his/her substance abuse disorder.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, facility policies, facility investigation reports, interviews, and observations, it was dete...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, facility policies, facility investigation reports, interviews, and observations, it was determined that the facility failed to: 1. Assess known smokers on admission, re-assess residents deemed as safe smokers after they were found to be unsafely smoking, and adequately supervise residents while smoking. 2. Failed to prevent a Resident with documented unsafe use of smoking material from having smoking material in their room. 3. Failed to ensure that a resident's room was free from hazards. This was evident for 8 of 27 residents reviewed for smoking/accidents. (Resident #78, #41, #90, #63, #28, #463, #464 and, #368)
The findings include:
1.) On 10/16/2023 at 10:32 AM, the surveyor reviewed Resident #78's safe smoking assessment completed on 5/4/23 and signed on 6/5/23. The assessment stated Resident #78 was a safe smoker but required supervision.
On 10/16/2023 at 9:24 AM, the surveyor reviewed an investigation completed by the facility for an event that was reported to have happened on 6/1/2022. In the investigation report, the Nursing Home Administrator (NHA) states that a staff member, who was attempting to provide care for the residents, detected smoking activity due to an unpleasant odor emanating from the room.
It further stated that Resident #78 was found smoking in his/her room.
On 10/12/23 on 8:30 AM, the surveyor reviewed a progress note written by Licensed Practical Nurse (LPN) Staff #70. The note stated Resident #78 was educated on the risk of smoking in the room, specifically the risk of a fire and the potential result in death. The Resident verbalized an understanding and the note further stated that staff would encourage and support safe smoking in the right designated area.
On 10/18/23 at 9:44 AM, the surveyor reviewed Resident #78's care plan. A care plan was initiated on 6/1/23 and stated, Resident #78 is a smoker and was found smoking in his/her room. The care plan was updated on 8/20/23, and included an incident on 8/6/23 where Resident #78 was reported smoking in his/her room and another incident on 8/20/23 where Resident #78 was observed smoking in another resident's room. It was updated again on 10/18/23 and stated Resident #78 was observed smoking in the room on 10/17/23.
On 10/27/2023 at 11:09 AM, the surveyor conducted an interview with Regional Director of Clinical Operation Staff #39. During this interview Staff #39 stated that any resident that smokes within their room is considered an unsafe smoker.
On 10/27/2023 at 11:55 AM, the surveyor showed staff #39 documentation that indicated Resident #78 was smoking in the room on several occasions and most up-to-date safe smoking assessment completed on 6/23/23 assessed Resident #78 as a safe smoker.
2.) On 10/16/23 at 10:32 AM, the surveyor further reviewed documentation included in the investigation report from the 6/1/23 incident. Information about an additional Resident was included in the report regarding Resident #41.
In the facility's investigation report, a progress note written by LPN staff # 70 was included. The note was dated 6/5/23 and stated that Resident #41 was educated on the risk of smoking in the room.
On 10/18/23 at 9:44 AM, the surveyor reviewed Resident #41's care plan. The review revealed Staff #70 initiated a care plan on 6/1/23 that stated Resident #41 was found smoking in their room.
On 10/25/23 at 9:24 AM, the surveyor reviewed Resident #41's progress notes. On 6/1/23 a note written by Wellness Program Director Staff #29 described that Resident #41 was observed coming out of the bathroom where smoke and the smell of Marijuana was noted. In the note Resident #41 confirmed he/she had been smoking in the room. On 6/25/23 a note was written by LPN Staff #47 at 11:02 AM. The note described as strong smell coming from Resident #41's room and when asked, Resident #41 apologized for smoking. An additional note written on 10/4/23 by LPN Staff #24 stated Resident #41 was found smoking cigarettes behind the closed door. The note further states this is not the first time Resident #41 exhibited this behavior.
On 10/25/23 at 9:30 AM, the surveyor reviewed Resident #41's safe smoking assessments. Resident's #41's most recent safe smoking assessment was dated 6/5/23 and indicated that Resident #41 was a safe smoker and required supervision.
3.) On 10/24/2023 at 4:55 PM the surveyor reviewed an investigation report the facility conducted from an incident that happened on 8/18/23. The report stated that Resident #78 and Resident #90 were found smoking in a room together in a room with another Resident that was on oxygen.
On 10/16/2023 10:48 AM, the surveyor reviewed Resident #90's medical record. The review revealed that Resident # 90 had an assessment conducted for safe smoking on 7/24/23. The assessment indicated Resident #90 had a dexterity problem and appeared to have physical limitations that interfere with the ability to perform safe smoking techniques. The observation section of the assessment described that the resident was able to hold tobacco material safely and extinguish material completely. Resident #90 was determined to be an unsafe smoker and needed supervision.
On 10/25/2023 3:12 PM, the surveyor reviewed a census report from the facility from August 2023.The review revealed that Resident #90 was roommates with Resident #10.
On 10/24/2023 at 11:59 AM, the surveyor reviewed Resident #10's medical record. Further review revealed that Resident #10 had a Minimum Data Set assessment completed 8/3/23. In section O, it was documented that Resident #10 was on oxygen.
On 10/25/23 at 9:41 AM, the surveyor reviewed a progress note written on 8/18/23 by Licensed Practical Nurse (LPN), Staff #24, and stated Resident #90 was caught smoking with Resident #78 in Resident #90's room, in which the roommate of Resident #90 was on oxygen.
On 10/24/2023 11:39 AM, the surveyor conducted an interview with Resident #10. During this interview the surveyor noted an oxygen concentrator next to resident #10's bed. During the interview, Resident #10 confirmed that Resident #90 was his/her roommate and smoked in the room. Resident then stated a roommate after Resident #90 also smoked in the room and stated it was Resident #63.
On 10/25/2023 3:12 PM, the surveyor reviewed a census report from the facility from September 2023. The review revealed that Resident #63 was roommates with Resident #10 after Resident #90 left.
4.) On 10/24/2023 11:39 AM, the surveyor Reviewed #63's medical record. The review revealed a care plan dated 7/29/23 that stated, Resident #63 has behavior issues, non compliance, and smokes in the room. Further review revealed Resident #63 was placed in the room with Resident #10 on 8/29/23. This was after Resident #10 was identified as being at risk due to non-compliance of smoking in the room by his/her previous roommate, Resident #90.
On 10/24/23 at 11:40 AM, the surveyor reviewed a progress note written by LPN Staff #24 on 10/4/23 that stated Resident #63 was in the room with a group of friends smoking cigarettes behind closed doors. The whole room was smelling, and one could see smoke in the room and cigarette butts and ashes on the table.
On 10/25/23 at 9:30 AM, the surveyor reviewed Resident #63's most up-to-date safe smoking assessment. The safe smoking assessment was dated 6/5/23 and indicated Resident #63 was a safe smoker requiring supervision. There was no safe smoking assessment documented after Resident #63 was noted to be smoking in his/her room.
On 10/27/2023 at 11:55 AM, the surveyor showed Staff #39 the documentation from Resident #63 medical record where it was documented that the Resident was smoking in the room, however, the most up-to-date safe smoking assessment, completed on 6/5/23, stated Resident #63 was a safe smoker.
5.) On 10/25/23 at 9:24 AM the surveyor reviewed Resident #28's medical record. The review revealed that Resident #28 had a care plan that was created on 7/31/23 and stated Resident #28 was observed smoking again in the room despite education. Further review of Resident #28's medical records revealed the most up-to-date safe smoking assessment was completed on 6/3/23. In this assessment Resident #28 was considered a safe smoker, however in the personal protection section a comment was written stating, keep reminding that smoking is not allowed in the rooms.
On 10/27/2023 at 8:54 AM, the surveyor interviewed Licensed Practical Nurse (LPN) staff # 21. During this interview staff #21 stated that on admission the nurses assess if a resident smokes. Staff # 21 stated this is done on admission and done quarterly as well. Staff #21 further stated that the computer can tell her when the assessment is due to be completed. She stated that if a resident is found to be smoking in their room, she would consider them an unsafe smoker.
6.) On 10/27/2023 at 9:24 AM, two surveyors made an observation on the 4th floor where there was a strong odor of cigarette smoke in the hallway. Both surveyors knocked and went into the room of Resident #464 and Resident #463, where the odor of smoke was amplified. The surveyors interviewed Resident #464 and Resident #463 in their shared room. Both Residents stated they were smokers but denied smoking in the room.
On 10/27/23 at 10:30 AM, the surveyor reviewed Resident #464's medical record. The review revealed that Resident #464 was admitted on [DATE]. No assessment was completed to evaluate the safety of the resident's smoking.
On 10/27/23 at 10:33 AM, the surveyor reviewed Resident's #463 medical records. The review revealed that Resident #463 was admitted on [DATE]. No assessment was completed to evaluate the safety of the resident's smoking.
On 10/27/23 at 9:32 AM, the two surveyors walked into the dining and activities room on the first floor. Within this room, the doors leading to the smoking patio were closed, and a cart was located next to the door. Several residents were outside smoking. No one was by the door. A person was noted to be across the room, turned away facing the vending machine on the opposite wall.
On 10/27/23 at 9:33 AM, the person who was at the vending machine turned and walked over to the cart by the smoking patio and stated she was an Activities Assistant Staff #11. At this time the Restorative Aide, Staff # 68, assisted Resident #27 to the smoking area and asked Staff #11 for a smoking apron. Staff #11 opened the cart and gave Staff #68 a smoking apron for Resident #27. The surveyor asked Staff #11 if any of the Residents smoking out on the patio needed to be supervised. Staff #11 stated, all those Residents that were able to get to the patio themselves can account for themselves and do not require her supervision. She further stated, she is expected to supervise Resident #27. Staff #11 explained for any Residents to get out onto the smoking patio she would have to enter a code but they can let themselves back in by pushing a button that is located on the outside door.
On 10/27/23 at 9:37 AM, both surveyors observed the courtyard smoking area.
On 10/27/23 at 9:38 AM, the surveyor interviewed Resident #41. During this interview Resident #41 stated the burn holes on his/her sweatpants were from smoking but the pants were old and this happened a long time ago. After the interview the resident was observed throwing the lit end of his/her lit cigarette on the ground.
On 10/27/23 at 9:52 AM, the surveyor walked inside from the smoking patio and reported to Staff #68, who was at the smoking cart, that that Resident #41 threw his/her lit cigarette butt on the ground. Staff #68 stated that Staff #11 had just walked away to get coffee started for the next Resident activity. She further stated she normally does not supervise smoking and then stated, I don't know what they do for smoking breaks. She followed up and stated, Staff #11 would be returning shortly. Staff #68 was observed walking out onto the smoking patio and talking to Resident #41.
On 10/27/2023 11:09 AM, the surveyor conducted an interview with the Regional Director of Clinical Operation Staff #39. During this interview Staff #39 stated that any resident that smokes within the room is considered an unsafe smoker. She further stated the nurses are the ones that conduct the assessment and would assess using multiple factors to decide if a Resident was a safe smoker. She further stated that all residents should be monitored while smoking. The surveyor asked how it is communicated if a Resident is a safe smoker or requires interventions. Staff #39 stated if anyone is observed smoking within their room the staff should let leadership know, leadership should search the room with consent of the resident. If they object the police should be notified, however the police do not always respond to this type of request. Nursing should be documenting any unsafe smoking and documenting who they notified.
On 10/27/23 at 11:50 AM, the surveyor conducted an interview with the Regional Director of Operations Staff #69. Present during the interview was the Nursing Home Administrator and Staff #39. Staff #69 stated that they often smell smoke in the building but have never seen a resident actively smoking. He further stated if we do see a resident smoking, we have a process in place and expect the process to be followed for all residents that are found smoking within the building. If we continue to suspect it, we give a behavioral contract and search the room. We also get the police involved if they refuse the search. If they continue to not follow the rules, we will give a 30 day notice and let the judge decide. He further stated however, sometimes when we do this and the judge decides they should be discharged , we still must keep them until we can establish a safe discharge and they would continue to reside here.
The Administrator followed the interview by stating all Residents sign a smoking agreement when they are admitted and are aware of the smoking expectations.
On 10/27/2023 at 11:55 AM, the surveyor showed the documentation from Resident #63, Resident #78 and Resident #28, where there was documentation of the Residents smoking in the room. At this time the Administrator confirmed that the smoking protocol was not followed for those residents.
Staff #69 confirmed that if a resident smokes within the room they are considered to be an unsafe smoker. The surveyor followed up by and showed the Staff #69 the most up to date smoking assessments completed for these residents.
Resident #63's most recent safe smoking assessment was completed on 6/5/23 and was assessed as a safe smoker with supervision.
Resident #78's most recent safe smoking assessment was completed on 6/23/23 and was assessed as a safe smoker with supervision.
Resident #28's most recent safe smoking assessment was completed on 6/3/23 and was assessed as a safe smoker with other in the comment. The surveyor also informed Staff #69 that there were two residents admitted in September that were documented as smokers and had no safe smoking assessment completed.
On 10/27/23 at 12:11 PM, Staff #39 confirmed that education was needed to address non-adherence to the smoking policy, activities personnel should be educated on supervision and nursing needed to be educated on assessments.
The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the
Federal definition of Immediate Jeopardy and the facility was verbally notified of this
determination on 10/27/23 at 7:00 PM. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by OHCQ at 11:37 PM after 4 initial plans were submitted at 8:48 PM, 10:59 PM, 11:20 PM, and 11:29 PM.
The plan included: Reviewing and updating safe smoking assessment and skin assessment for Residents #78, #41, #90, #63, #28, #463 and #464. The Nursing Home Administrator (NHA) to educate the Activities department on the process of providing supervision during smoke times. The facility's smoking policy was updated to include smoking assessments to be done on admission and upon noncompliance with the smoking policy as needed. The date of completion was 10/31/23.
Additionally, the facility's plan for removal included the following: the Regional Director of Clinical Operations to complete a house wide audit of current residents to evaluate for following: If current smokers were assessed upon admission. Review Residents with non-compliant smoking behaviors, identified in care plans, and ensure reassessed for safe smoking are completed. Evaluate supervision of smoking during smoking times and supervision on units to ensure Residents are adhering to the facilities smoking policy.
Listed the following actions would be taken if non-adherence to the smoking policy were found: The NHA will be notified, behavioral contract will be initiated, a room search done with permission, and if a Resident continues to be non-complaint the police will be notified. The date of completion was 10/31/23.
The Regional Director of Operations will update the current smokers list with a completion date of 10/27/23.
The education plan included the Regional Director of Operations to educate the Unit Managers on the importance of adhering to the facility's smoking policy and ensure smoking is assessed on admission and any noncompliance actions will be followed as outlined. The Unit Managers will then educate all licensed staff. The Administrator will educate the facility staff on the facility' s smoking policy.
The plan for monitoring included the Director of Nursing to complete a record review audit to validate smoking assessments were completed appropriately and conduct observational rounds. The audits are to be performed randomly once a week for four weeks and then monthly for three months. The Audits will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for review. The NHA will complete observational rounds once a week during smoke times as well as on the units to validate that supervision is being provided. The audits will be done once a week for four weeks and then monthly for three months. The Audits will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for review.
After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on 11/2/23 after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents.
7.) On 10/23/23 at 9:57 AM, the surveyor reviewed a progress note written by a Nurse, Staff #90 on 11/19/22. The note describes that the nurse was smelling cigarette smoke from the hallway and while checking residents' rooms, She opened Resident #368's door. The note further describes the room was filled with smoke and 2 cups filled with water had parts of cigarette in them. The note stated education was given on the risk of smoking and that smoking in the room was not allowed. Resident #368 refused to give up her lighter and cigarettes that were found in her room.
On 10/23/23 at 9:31 AM, the surveyor reviewed the safe smoker assessment completed on 12/4/22 for Resident #368. The assessment states that Resident #368 has a visual deficit that impairs ability to smoke safely. An observation was documented on the assessment and further stated, Resident was not able to extinguish smoking material completely in an appropriate receptacle. Also noted on the assessment was documentation that stated Resident #368 lies in bed and smokes cigarettes. The assessment further stated Resident #368's roommate is on oxygen. After the statement unsafe smoker was checked with an explanation that stated, Resident smokes in room while in bed and lights are off, Resident has poor vision, and roommate is on oxygen. Supervision was checked with a comment after; Resident keeps cigarettes in room, ashes in bed and on floor, additionally Residents uses paper cups to put out cigarettes.
On 10/23/23 at 9:40 AM, the surveyor reviewed the smoking policy which was updated on 1/17/23. In the policy section 13 states, smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. The last statement in the policy states, flammable materials are not allowed in resident rooms. These materials include, but are not limited to, candles, matches, lighters, E-cigarettes, pipes, diffusors, ect. If a resident violates this rule, they may be issued a 30-day involuntary discharge.
Further review revealed a note written on 1/16/23 from Registered Nurse (RN) Staff #91. The note describes Resident #368 reported he/she had lit a candle by the television then fell asleep. The television had caught on fire and the Resident was able to put out the fire but the television was destroyed. The nurse further stated she had warned Resident #368 of the risks of smoking in the room over the last few days. There was no evidence in the medical record that indicated staff took possession of Resident #368's prohibited smoking materials.
On 10/23/23 at 11:46 AM, the surveyor conducted a phone interview with the previous Nursing Home Administrator Staff #52. During this interview Staff #52 confirmed that smoking materials were not allowed at the bedside. Staff #52 remembered the fire from Resident #368 and stated she believed a staff member had given Resident #368 the candle as a Christmas present. She stated a house wide audit was done and no other candles were found. She also stated education was done for staff and Residents that candles were not permitted. She remembers Resident #368 was given a 30-day involuntary discharge.
8. On 09/28/2023 at 11:24 AM, Resident #63 said that he/she cannot get across their room in his/her wheelchair without hitting a power strip block that hangs off the wall.
A subsequent observation revealed that hanging off the wall was a tan, multiplug power strip block. It was hanging 13 above the floor and the bottom stuck out 9 from the wall. It was being utilized as an extension cord by Resident #63's roommate.
On 09/29/2023 at 1:10 PM, Staff #3, the Unit Manager, was shown the power strip and acknowledged it's a hazard.
On 10/04/2023 at 9:50 AM, Staff #7, the Maintenance Director, observed the hanging power strip and explained that the facility does not provide power strips or extension cords, usually it's visitors that bring them and that they are not approved. Per Staff #7, the problem is there are not enough outlets in the room. He acknowledged the hanging power strip was a safety concern.
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
QAPI Program
(Tag F0867)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that the facility failed to use the Quality Assurance Performance Impr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that the facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze serious preventable adverse events (SPAE drug overdoses). The first identified occurrence was on [DATE] (Resident #131) which resulted in resident death. Without effective QAPI intervention, 22 additional drug overdose SPAEs occurred (Residents #2, #53, #58, #63, #66, #76, #90, #93, #101, #118, #132, #136, #147, #149, #154, #160, #267, #268, #269, #373, #418, and #420).
The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 10:00 AM on [DATE].
The findings include:
The Centers for Medicare and Medicaid Services (CMS), defines Quality Assurance (QA) and Performance Improvement (PI) as a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem-solving.
Narcan is a medication that rapidly reverses an opioid overdose.
On [DATE] at 8:10 AM, the surveyor requested a list of all residents who received Narcan. The Regional Director of Clinical Operations (RDCO) stated the information is not easily accessible and she would have to go through medical records.
On [DATE] at 11:00 AM the (RDCO) provided a list of the following Residents: #2, #53, #58, #63, #90, #93, #101, #136, #147, #149, #154, #160, #267, #268, #269, #373, #418, & #420, that received Narcan following suspected illicit drug abuse from the dates of [DATE] through [DATE].
The surveyors additionally identified Residents #66, #76, #118, #131, and #132 on [DATE] at 7:30 AM during record reviews.
The overdoses included six fatalities (Residents # 53, #131, #132, #136, #154, and #160). The surveyors reviewed the six death certificates on [DATE] at 9:05 AM for cause of death. Resident #53 died on [DATE] of Mixed Drugs (Fentanyl, Despropionyl Fentanyl, methadone, and oxycodone) intoxication with cocaine use. Intoxication. Resident #131 died on [DATE] of Acute Diphenhydramine and Fentanyl Intoxication. Resident #132 died on [DATE] of Combined Drug (Fentanyl, Despropionyl, Para-fluorofentanyl, and Xylazine) Intoxication. Resident #136 died on [DATE] of Fentanyl and Oxycodone Intoxication. Resident #154 died on [DATE] of Fentanyl and Despropionyl Fentanyl. Resident #160 died on [DATE] of Fentanyl intoxication.
The Medical Director was interviewed by the surveyors on [DATE] at 03:15 PM. When asked about his role with the facility he stated that he conducted the weekly risk meetings, QAPI meetings, and participated in the Facility Assessment. He added the QAPI team looks at residents at risk for any concerns, treatment, family, weights, altered mental status, wounds, rehab, psychotropic new meds, inappropriate meds, and diagnosis. When asked if drug overdoses were discussed the response was, Of course, we refer overdoses to psych. We do counseling and methadone. When asked if the facility tracks and tallies drug overdoses, he responded they track behaviors, and to refer to the risk minutes for details. No documentation was provided by the facility on tracking behaviors and tallying resident drug overdoses.
When asked about the QAPI meeting, he stated he conducts the meeting and that all disciplines report at the Committee meetings. The Director of Nursing reports at risk residents. When asked how they prioritize concerns he stated, We do skin sweeps and identify skin breakdowns. When further asked what his biggest concern is with the facility he stated: drug use, drug use, drug use. When asked if drug overdoses were discussed in the QAPI meetings, he stated that the facility admits residents with Substance Use Disorder (SUD). We do counseling, educate, refer to clinics, methadone, and psychiatric care. When asked how many overdoses there were in [DATE], he stated that he could get the exact number. He stated, we give Narcan and call 911 for all overdoses. He further stated that drug overdoses should be a sentinel event and he believed all drug overdoses should be reported to the state.
On [DATE] at 03:46 PM when the Medical Director was asked if the facility had conducted a performance improvement plan on drug overdoses, he responded that they had PIPs in process for only smoking and MOLST concerns.
The surveyor reviewed the [NAME] Park 2022 - 2023 QAPI plan, the Facility Assessment, and QAPI committee notes on [DATE] at 9:57 AM. The facilities plan indicated that the QAPI Methodology uses a systemic approach to determine the root cause of identified problems using a variety of tools including Performance Improvement Projects (PIP), Root Cause Analysis (RCA), and Failure Mode and Effect Analysis (FMEA). The facility's plan further stated that PIPs prioritize high-risk, high frequency, and/or problem prone areas that impact the quality of care and quality of life for the residents and the QAPI Committee's overall responsibility is to develop and modify the plan, analyze information, and set priorities for PIPs. However, there was no evidence that drug overdoses were tracked, reviewed, or analyzed by the QAPI committee.
During an interview on [DATE] at 2:00 PM, the Administrator stated that there was not a PIP for drug overdose because it wasn't occurring at the frequency it is now. However drug overdoses occurred for Resident: #131 on [DATE], #136 on [DATE], #160 on [DATE], #66 on [DATE], [DATE], and [DATE], #118 on [DATE], #149 on [DATE], #132 on [DATE], #2 on [DATE], #147 on [DATE], #154 on [DATE], #76 on [DATE], #93 on [DATE], #373 on [DATE], #58 on [DATE], #53 on [DATE], #90 on [DATE] and [DATE], #418 on [DATE], #101 on [DATE] and [DATE], #269 on [DATE] and [DATE], #63 on [DATE], #267 on [DATE], #420 on [DATE], and #268 on [DATE].
During an interview on [DATE] at 2:15 PM, the Wellness Director stated that tracking of overdoses just started in October. She confirmed that although they had discussed drug use in the QAPI meeting, they had not put a PIP in place. The facility had failed to initiate an effective QAPI response after 23 SPAEs over 16 months beginning on [DATE], that by the time of the survey had resulted in six resident deaths.
The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by OHCQ on [DATE] at 6:05 PM after 3 initial plans were submitted to the surveyors at 1:19 PM, 4:22 PM, and 5:45 PM.
The abatement plan included: The education of the QAPI Committee on the process of utilizing a systemic approach to ensure that a high-risk event such as drug overdoses are examined during QAPI meetings by tracking, reviewing, and analyzing the root cause of overdoses and providing performance improvement plans tailored to the root cause to ensure adequate management of residents with Substance Use Disorder (SUD) to reduce relapse or the risk of drug overdose by the Regional Director of Clinical Operations (RDCO). Identification of current residents with SUD to evaluate if they are tracked, reviewed, and analyzed for the root cause to ensure adequate interventions to reduce relapse or the risk of drug overdose. The residents identified by the screening tool will be discussed in the weekly risk meeting and behaviors reviewed for an appropriate plan of care. The Director of Nursing would educate the Licensed Nurses, Agency Nurses, and new hires on the importance of screening residents using the screening tool to identify a history of illicit drug use, interest in treatment, and screening for suspected drug overdose when they are found to possess drugs. The Administrator will complete random audits monthly for four months, and Quarterly for three Quarters, to validate that the QAPI Committee follows the process of tracking, trending, reviewing, and analyzing high risk events to validate that the performance improvement plan to reduce relapse or drug overdose is initiated, verify the screening tool has been completed upon admission for residents with a history of substance use, and validate that they have been offered treatments by the facility.
The Immediate Jeopardy was removed on [DATE] after the survey team validated that the facility met the compliance date of their action plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on interview and observation, the facility failed to provide a bariatric bedside commode for a resident's use. This was evident for 1 (# 417) out of 2 residents reviewed for accommodation of nee...
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Based on interview and observation, the facility failed to provide a bariatric bedside commode for a resident's use. This was evident for 1 (# 417) out of 2 residents reviewed for accommodation of needs.
The findings include:
On 09/28/23 at 9:30 AM, during interview Resident # 417 stated that s/he was not able to go to the bathroom because the bedside commode the facility provided was not big enough to fit her/his body. S/he is unable to use the bathroom because the toilet is too low, and s/he can't get back up. The resident stated that s/he asked for a bariatric bedside commode a few times, but had not received one yet. The surveyor observed a standard sized bedside commode at the bedside. No assistive devices were present in the bathroom.
During an interview with GNA # 35 on 09/28/23 at 10:56 AM, the surveyor asked for the process for obtaining bariatric equipment. The response was maintenance supplies the bed and physical therapy supplies the commode. When asked if it was hard to get the equipment she replied no, we just ask.
On 09/28/23 at 10:58 AM, LPN # 21 stated, the process for obtaining a bariatric bedside commode is to go get a bariatric commode from the Rehab department for the resident.
During an interview on 09/29/23 at 09:53 AM, the Physical Therapy Director # 26 stated the commode was delivered Thursday before the resident was discharged and indicated the bariatric bedside commode in the therapy room.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to honor the resident's right to participate in family events outside the facility. This was evident for 1 (Resident #4...
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Based on interview and record review, it was determined that the facility failed to honor the resident's right to participate in family events outside the facility. This was evident for 1 (Resident #46) out of 1 resident reviewed for resident rights.
The findings include:
On 10/13/23 at 09:50 AM during an interview, Resident#46 stated that he/she requested a Leave of Absence (LOA) on two different occasions: 8/25/23 & 9/5/23, however, only the first one was approved for 8/25/23 from 7:00 AM until 11:00 AM. Resident #46 followed the facility policy and filled out both requests 4 days prior to the requested leave. He/she remembered making the requests to staff at the third-floor nurse's station.
An interview was conducted on 10/13/23 at 11:32 AM with the Unit Manager (Staff #3) who confirmed that he received both of Resident # 46's LOA requests. He stated that LOA requests were normally approved by him unless there was a medical risk concern, then it was forwarded to the physician for review.
Furthermore, due to facility applied the Leave of Absence policy under therapeutic Bed Hold Day so the request was also forwarded to the Business Office Manager (Staff #44).
On 10/13/23 at 11:40 AM Interview of Staff #44 revealed she had a conversation with Resident #46 that LOA was limited to 18 calendar days in a year. However, Resident #46 only had 2 requests, each was a 4-hour absence. Additionally, Staff #3 reported that the resident's LOA paper was lost in the chart so he could not provide any documentation.
On 10/16/23 at 08:30 AM, an order page for 8/25/23 from the Primary Physician (Staff #50) stated, may to LOA for 4 hours (7A-11A) with his father. There was no documentation on 9/5/2023' of the LOA request from Staff #50. A phone interview was conducted on 10/16/23 at 09:51 AM with Staff #50 regarding LOA process, she stated normally it was for therapeutic events like medical appointments that were approvable. When asked about residents' family or community activities LOAs, she indicated all Long-Term Care residents' requests were okay to approve by the unit managers, but other residents' requests had to be reviewed by her. She reviewed them while on site because floor nurses normally altered her. She had no recollection of this resident's LOA request on 9/5/2023, she planned to provide that information in person later.
On 10/17/23 at 8:50 AM the surveyor requested an interview with Staff #50 and requested that the 9/5/2023 LOA documentation be provided.
On 10/19/23' at 9:30 AM the surveyor notified facility staff that no 9/5/2023 LOA documentation was provided to support the denial.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed record, a staff interview, it was determined that a resident was not given an admission ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed record, a staff interview, it was determined that a resident was not given an admission contract. This was evident for 1 (Resident #141) of 112 intakes reviewed during an annual certification survey.
The findings include:
Review of complaint MD00175504 on 11/02/23 revealed an allegation Resident #141 had been admitted to the facility for over a month without an admission contract.
A review of Resident #141's closed medical record on 11/02/23 failed to reveal any documentation Resident #141 had received an admission contract. Resident #141 was admitted to the facility on [DATE]. Resident #141 was transferred to another long-term care facility on 02/18/22 per her wishes.
In an interview with the facility, on 11/20/23 at 11:50 AM, the administrator stated that he was unable to locate a completed admission contract for Resident #141 after being admitted to the facility and couldn't answer why the contract had not been issued.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on reviews of a facility reported incident and staff interview, it was determined that a staff member removed money from a resident's account without the resident's permission. This was evident ...
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Based on reviews of a facility reported incident and staff interview, it was determined that a staff member removed money from a resident's account without the resident's permission. This was evident for 1 of 112 intakes reviewed during an annual recertification survey.
The findings include:
Review of facility reported incident MD00184909 on 11/01/23 revealed details that staff member #87 was asked by Resident #144 to go buy him some cigarettes on 10/22/22. In addition to buying the smoking materials, staff member #87 also withdrew $40 dollars cash. Review of staff member #87's written statement, dated 11/03/22, staff member #87 admitted that Resident #144 had not given her permission to remove an additional $40 cash from the debit card account on 10/21/22. Review of Resident #144's written statement, Resident #144 stated that he had not given staff member #87 permission to withdraw an extra $40 cash from his account. Resident #144's statement also indicated that Resident #144 confronted staff member #87 on 10/21/22 about the $40 removed from the account. Resident #144 informed the facility administrator that the staff member returned $25 and stated that she spent the rest of the money on food because she was hungry. Resident #144 told staff member #87 that she should have asked him first.
In an interview with the facility Director of Human Resources (HR) on 11/14/23 at 3:15 PM, the HR Director confirmed the facility substantiated the allegation of misappropriation of funds and terminated staff member #87 on 11/03/22.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on clinical record review, review of a complaint, and staff interview it was determined that the facility failed to ensure proper planning on an issued 30 day discharge. The findings were eviden...
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Based on clinical record review, review of a complaint, and staff interview it was determined that the facility failed to ensure proper planning on an issued 30 day discharge. The findings were evident for 1 (#165) out of the 140 residents that were part of the survey sample.
The findings are:
A review of Resident #165's clinical record on 10/19/23 to investigate intake #MD00175238 revealed that on 8/3/22 a meeting was held with the Ombudsman, the resident, and the resident's spouse. The resident had been caught smoking in an inappropriate place with the potential of harm to self and to others. The resident and spouse had been warned before but the resident is impulsive without regard to safety of self or others. The spouse understood why a 30-day involuntary discharge was issued secondary to facility not being able to accommodate the resident's need to smoke. Resident requested a facility with more opportunities for smoking. Spouse will call other facilities near home and facility said they would call facilities in the city. Spouse agreed to the discharge.
Further review revealed the resident was still in the facility after the 30-day involuntary discharge was issued. Another meeting was held with the resident and spouse on 3/2/23. The spouse was notified of the resident smoking. Spouse agreed to work on getting the resident discharged within the next two weeks.
A care conference meeting was held on 3/14/23. Resident attended with spouse, rehab nursing, a member of the business office, a service coordinator from the wavier program (a government program where an individual receives needed care at their home), the Administrator, and a friend of resident. During the meeting the Administrator told the spouse that a safe place to live must be in place for the discharge to occur. Spouse announced that the resident was going to be discharged to an occupied apartment with a roommate who would be the caregiver. Potential roommate was called, and he informed the team that the rental office has not yet approved. The Administrator informed the spouse that the correct steps need to be followed for a safe discharge. The Social Worker tried to explain the benefits of continuing the waiver process. The spouse stood and announced the resident was leaving against medical advice. They both left the facility.
The Social Worker (Staff #14) was interviewed on 10/19/23 at 10:29 AM. She said when a resident smokes in the facility they go on contract. Activity staff put them on the contract. If resident violates the smoking agreement, then the contract starts and activity enforces. Social work handles contracts for physical aggression. Rescinded 30-day notices are kept in the business office.
The Administrator was interviewed on 10/19/23 at 1:30 PM. He said he checked with the business office and there were no 30-day discharge notices on record. I informed the Administrator that a 30-day discharge was noted in the clinical record. He said he would check with the corporate lawyers.
The Administrator returned to the survey team meeting area on 10/19/23 at 1:42 PM. He stated a 30-day discharge was not given because resident left discharged against medical advice (AMA). This surveyor said the 30-day notice was issued earlier in the resident's stay and then he was shown where it mentioned the 30-day discharge in the care plan. He replied that it might have been for a different resident. I read it to him to show it was not likely to be someone else's. He replied understood. He also said he has a phone call into the lawyers.
The Administrator supplied an email chain on 10/20/23 at 11:34 AM. The email chain implied that there were two involuntary discharge notices, but neither was in the clinical record. Email chain states the second one was rescinded about the time of actual discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 9/27/2023 at 9:09AM, surveyors observed Resident #517 sweating, restless, sitting up in bed, and complaining I'm so hot. R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 9/27/2023 at 9:09AM, surveyors observed Resident #517 sweating, restless, sitting up in bed, and complaining I'm so hot. Residents' speech was slurred and hard to understand during conversation.
On 9/27/2023 at 9:14AM, Surveyors notified Unit Manager, Staff #1 of residents' condition. Surveyors observed Staff #1 knock on Resident #517's door, announce herself, and then enter the resident's room. Staff #1 placed the resident's breakfast tray on the bedside table and raised the head of the bed.
On 9/27/2023 at 9:50 AM, review of Resident #517 electronic medical records confirmed that the resident was admitted on [DATE] with diagnoses that included, but was not limited to, end stage renal disease (kidney disease), dependence on renal dialysis, hypoglycemia, hypotension, osteomyelitis (bone infection), laminectomy, fusion of spine, and chronic postprocedural pain. The admission assessment dated [DATE] shows that the resident was cognitively intact, alert, and able to make his/her own decisions.
On 9/28/2023 at 8:33 AM, during record review, surveyors discovered a nursing progress note written by Staff #1 on 9/27/2023 at 10:35 AM which stated that Resident #517 was being transferred to the hospital emergency room due to hypoglycemia (low blood sugar).
Subsequent review of the medical record, revealed Resident #517 is self representative and an attempt was made to reach the resident's significant other by phone.
On 9/29/2023 at 1:09 PM, during record review, surveyors discovered an order created on 9/29/2023 at 11:22 AM for Resident #517 to be sent out to hospital immediately for low blood sugar.
On 10/13/2023 at 9:55AM, surveyors conducted an interview with the interim DON (Director of Nursing), which revealed that she was unsure of the transfer/discharge policy for the facility. Surveyors reviewed the concern with the interim DON regarding failure to provide written transfer notice to Resident #517 or his/her resident representative.
An interview was held on 10/18/2023 at 7:55 AM with Unit Coordinator, Staff #21 who confirmed that there was no written notice sent to Resident # 517 nor to his/her representative.
The identified concern that the written notice of transfer was not provided for each of Resident #517's hospitalizations were reviewed with the Regional Director of Clinical Operations (RDCO) and the Administrator on 11/17/2023 at 12:30 PM and again at the exit conference on 11/20/2023 at 12:30 PM.
Based on observation, record review, and interviews, it was determined the facility failed to: 1) provide written notice with the reason for transfer to a resident and 2) failed to notify the Ombudsman of residents that transferred timely. This was found evident of 2 of 7 (Resident #22 & #517) Residents reviewed for hospitalization during an annual and complaint survey.
The finding include:
1. On 9/28/23 at 11:52 AM, the surveyor conducted an interview with Resident #22. During the interview Resident #22 stated he/she had recently been transferred to the hospital.
On 10/2/23 at 1:43 PM, the surveyor reviewed Resident #22's medical record. The review revealed that Resident #22 was transferred to a hospital related to an unwitnessed fall.
Further review of the record revealed that Resident #22 had no documentation that a written notice was given to him/her informing him/her of the reason for transfer.
On 10/5/22 at 2:15 PM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the NHA stated he was only aware of the transfer summary that is completed by staff when a Resident transfers, and would have to follow up on a written notice.
As of 11/20/23 at the day of exit, no transfer notice was provided to the surveyor for Resident #22.
2. On 10/5/23 at 11:17 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the surveyor asked for the notification sent to the Ombudsman's office on the transfers and discharged residents. The NHA stated that the August transfers and discharges were not sent. He stated he would provide communication the previous administrator had sent.
On 10/5/23 at approximately 2 PM, the surveyor conducted a follow-up interview with the NHA. During the interview the surveyor was provided with an email that was sent to the Ombudsman office with a list of Resident transfers and discharges. The email was sent on 8/7/2023 and the date range of notification was May 1st through August 7th 2023. This meant that the notices from May were sent several months after the transfers and discharges occurred and any transfers or discharges that were done after the date of August 7th 2023 were not sent to the Ombudsman, as of yet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, it was determined that the facility failed to implement a process to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, it was determined that the facility failed to implement a process to ensure that residents and resident representatives were made aware of the facilities bed hold policy upon transfer to the hospital. This was found to be evident for 2 (Resident #517 and #22) of 7 residents reviewed for hospitalizations during the investigative portion of the survey.
The findings include:
A Bed Hold is the act of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. It should be provided to all facility residents regardless of payment source. Bed Hold policy should be disclosed in the admission packet during initial admission to the facility and it should be disclosed to resident and, if applicable, resident representatives at the time of transfer; if emergency transfer, within 24 hours.
1. On 9/28/2023 at 8:33 AM, during record review, surveyors discovered Resident #517, was admitted to the facility on [DATE] and was subsequently transferred to the hospital emergency room (ER) due to hypoglycemia (low blood sugar) on 9/27/2023 at 11:05 AM.
On 9/27/2023 at 9:50 AM, review of Resident #517's electronic medical records confirmed that the resident was admitted on [DATE] with diagnoses that included, but was not limited to, end stage renal disease (kidney disease), dependence on renal dialysis, hypoglycemia, hypotension, osteomyelitis (bone infection), laminectomy, fusion of spine, and chronic postprocedural pain. The admission assessment dated [DATE] revealed that the resident was cognitively intact, alert, and able to make his/her own decisions.
During subsequent review medical record, surveyors noted a nursing progress note written by Unit Manager, Staff #1 on 9/27/2023 at 10:35 AM which stated that Resident #517 was noted to be diaphoretic (sweating heavily), shaking, and unable to speak clearly, with a low blood glucose reading. The doctor was called, and an order was provided to send Resident #517 to the emergency room due to hypoglycemia.
During further review of medical record, surveyors noted that on 9/27/2023 at 5:39 PM, a transfer summary was completed by Staff #1. No bed hold noted.
On 9/29/2023 at 10:45 AM, during record review, Surveyors noted Resident #517 was readmitted on [DATE] at 7:30 PM.
On 9/29/2023 at 1:09 PM, during record review, surveyors discovered a physician's order written on 9/29/2023 at 11:22 AM for Resident #517 to be sent out to hospital immediately due to low blood sugar.
On 10/4/2023 at 6:40 AM, during an interview with licensed practical nurse (LPN), Staff #34, surveyors were informed that Resident #517 returned to the facility at 7:30 PM on 10/3/2023.
On 10/13/2023 at 9:55 AM, surveyors conducted an interview with the interim Director of Nursing (DON), which revealed that she was unsure of the bed hold policy for the facility. Interim DON stated that she would follow up with surveyors regarding the policy and try to find out where they are located. The surveyors requested a copy of the documentation that a written bed hold policy was given to the resident or resident representative. No documentation regarding Resident #517's bedhold was provided to the surveyors during the survey.
On 10/18/23 at 07:45 AM, during an interview with Unit Coordinator, Staff# 21, surveyors asked, What do you do when a resident has to be sent out to hospital? Staff #21 responded, We fill out the transfer summary in the resident's electronic medical record, make sure there is an order for transfer and change in condition documented. We fill out a Bed-Hold Policy form and the resident signs if he/she is alert and oriented, if not the resident representative is made aware (called) and noted on the transfer summary. Copy of the bed-hold is placed in the resident's chart. Then we write a progress note in the resident's chart.
On 10/18/2023 at 8:25 AM, surveyors conducted an interview with Unit Manager, Staff #32. Staff #32 stated that residents are informed of the reason for transfer or discharge at the time of assessment by the nurse or the physician based on a resident's condition. According to Staff #32, the residents are provided with a bed hold policy and provided surveyors with a blank official copy of the bed hold policy. It is filled out by the nurse, physician, and the resident signs the policy if they are alert and oriented. If the resident is not alert and oriented, the resident representative is called and gives phone consent for and informed of the transfer/ discharge. A copy goes in the patient chart and the other goes with the resident.
During record review on 10/18/2023 at 9:29 AM surveyors reviewed a bed hold policy in the resident's physical chart that was incomplete; it lacked Resident #517's signature to acknowledge receipt of the policy.
On 10/18/2023 at 9:45 AM, an interview was conducted with the Administrator. During the interview, the administrator stated we use the Bed Hold and Return Notification form. He stated that he went up to Staff #21 and asked her about the bed hold policy and she is aware of the policy. He stated that he asked Staff #34, and she did not know the policy. At that time, surveyors discussed concerns with the Administrator.
On 10/18/2023 at 9:55 AM, an interview with interim DON was conducted. Surveyors reviewed the with the interim DON the concern regarding failure to provide Resident #517 or his/her resident representative with a bed hold policy for his/her first transfer to the hospital on 9/27/2023 at 11:05 AM and then an incomplete bed hold policy for his second transfer to the hospital on 9/29/2023 at 11:58 AM.
Upon survey exit on 11/20/2023, the facility did not provide documentation to the survey team to indicate a bedhold policy was provided to Resident #517 when sent out to the hospital on 9/27/2023 or 9/29/2023.
2. On 9/28/23 at 11:52 AM, the surveyor conducted an interview with Resident #22. During the interview Resident #22 stated he/she had recently been transferred to the hospital.
On 10/2/23 at 1:43 PM, the surveyor reviewed Resident #22's medical record. The review revealed that Resident #22 was transferred to a hospital related to an unwitnessed fall.
Further review of the record revealed that Resident #22 had no documentation that a written notice was given to him/her regarding the bed hold policy.
On 10/11/23 at 11:32 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the surveyor asked if the facility provided written notice to Resident #22 regarding the facility's bed hold policy. The NHA stated he just recently inquired about this and he found that some nurses provide it and others do not. He stated he would look for the notice for Resident #22.
On 10/17/23 at 2:26 PM, the surveyor was provided a copy of the facility's bed hold notification form. The NHA stated he was unable to find Resident #22's bed hold policy notification and stated that education would need to be provided to ensure this form would be given on transfers and a copy kept in the record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately assess a resident for antipsychotic medications and to ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately assess a resident for antipsychotic medications and to accurately document an assessment. This was found to be evident for 2 (# 92 and #115) out of 8 residents reviewed for Minimum Data Set (MDS) accuracy.
The findings include:
According to CMS, the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
1. During a record review on 10/02/23 at 09:09 AM, the surveyor reviewed Resident # 92's Quarterly MDS dated [DATE] coded by former MDS Coordinator #84. For Section I, Active Diagnoses, Section I5900 Bipolar Disorder was coded and in section N0410 Antipsychotic medication was coded, however, Section N0450 A, Antipsychotic Medication Review was scored as not indicated. Therefore, Section N0450 B through E were not triggered.
According to CMS, the Resident Assessment Instrument (RAI) helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan.
On 10/02/23 at 11:07 AM, the surveyor interviewed the Resource MDS Coordinator # 28. When asked about the MDS coding process, she responded we follow the Resident Assessment Instrument (RAI) guidelines. Her response for how they code section N was we look at drug classifications. Asked about coding for resident for section N0410 and N0450, she stated N0450 should have been coded yes instead of no. She further stated she would amend the MDS right now.
During an interview on 10/03/23 at 09:22 AM, the Director of Nursing was notified that Resident #92's MDS had been coded incorrectly. She acknowledged the concern and stated that Resource MDS Coordinator would code it correctly.
On 10/4/23 at 11:10 AM, the surveyor confirmed that the corrected MDS had been transmitted on 10/2/23.
2. On 10/19/23 at 9:00 AM, the surveyor reviewed Resident #115's medical record and noted a Minimum Data Set (MDS) assessment completed on 1/15/23 had dashes through sections C titled, Cognition Patterns and section E titled, Behavior.
Further review of Resident #115's medical record revealed Resident #115 had a history of behaviors and was care planned for behavioral issues.
On 10/25/23 at 8:03 AM, the surveyor interviewed the Regional Minimal Data Set (MDS) coordinator Staff #65. During this interview Staff #65 stated the dashes were appropriate for the assessment because even though Resident #115 had documentation behaviors occurred during the evaluation timeframe, nursing did not indicate what type of behaviors. There was no narrative explanation found. Staff #65 stated this omission did not allow Resident #115 to be coded as having behaviors on the MDS conducted on 1/15/23. She further stated nursing would need to be educated on the importance of writing a narrative to the specific behaviors when indicating behaviors occurred.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with staff, it was determined that the facility failed to develop and impleme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with staff, it was determined that the facility failed to develop and implement a baseline care plan for a resident, requiring hemodialysis treatments and experiencing recurrent hypoglycemic episodes, that meets the professional standards of quality care. This was evident for 1 (Resident #517) of 13 residents investigated for care planning.
The findings include:
The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that are most likely to occur right after admission.
Hemodialysis is a treatment, using a dialysis machine, to filter wastes and water from your blood when your kidneys are no longer healthy enough to do so.
On 9/27/2023 at 9 AM surveyors conducted a tour of a unit. During the resident screening process, surveyors encountered a resident (Resident #517) on the unit who was experiencing a change in physical health condition. Surveyors immediately notified the resident ' s nurse.
On 9/28/2023 at 8:33 AM, during review of electronic medical record, surveyors discovered Resident #517, was transferred to the ER due to hypoglycemia (low blood sugar) on 9/27/2023 at 11:05 AM, shortly after being taken to the dialysis clinic within the facility.
On/9/28/2023, subsequent review of the electronic medical record, surveyors noted that Resident #517 was admitted to the facility 9/25/2023 with diagnoses, including but not limited to ESRD (end stage renal [kidney] disease), dependence on hemodialysis, hypoglycemia, osteomyelitis (bone infection), laminectomy, post procedural pain, heart failure, and high blood pressure.
Further review of Resident #517 ' s electronic medical record, revealed a physician ' s order for dialysis to take place on a Monday, Wednesday, Friday schedule.
On 9/29/2023 at 12:10 PM the facility produced Resident #517 ' s hospital Discharge summary dated [DATE], which revealed that the resident was diagnosed with ESRD requiring dialysis 3 days a week. The discharge summary documentation also stated that the resident had recurrent hypoglycemic episodes, during that hospitalization, requiring dextrose infusions (a solution used to provide your body with extra water and carbohydrates, or calories from sugar).
On 9/29/2023 at 12:20 PM, Surveyors noted during review of a document titled Dialysis Policy revised on 8/17/21, a section under, Policy Explanation and Compliance Guidelines:
1) Comprehensive care plans will be developed based on resident assessments, goals, and preferences in accordance with assessment and care plan procedures;
2) The care plan will reflect the coordination between the facility and the dialysis provider and will identify nursing and home dialysis responsibilities;
7) The care plan will be reviewed routinely and as needed for effectiveness, and revised as needed.
On 9/29/2023 at 12:35 PM, during electronic medical record review, surveyors discovered that a baseline care plan was developed on 9/25/2023. The baseline care plan did not show a plan of care to address dialysis needs for Resident #517 according to the facility's dialysis policy.
During an interview on 9/29/2023 at 10:00 AM with the Interim Director of Nursing (DON), surveyors and the interim DON reviewed the baseline care plan in Resident #517 ' s electronic record and the interim DON confirmed that the baseline care plan did not include an adequate dialysis plan of care or a plan of care for the resident's hypoglycemic care needs within 48 hours of resident ' s admission to the facility on 9/25/2023.
On 9/29/2023 at 1:09 PM, during record review, Surveyors discovered an order for Resident #517 to be sent out to hospital immediately due to low blood sugar levels.
On 10/03/23 at 07:56 AM , surveyors noted that Resident #517 was rehospitalized as of 9/29/2023 at 1:09PM due to hypoglycemia. He has not been able to receive dialysis since at the facility due to low BS and hospitalizations.
These identified concerns were reviewed with the interim DON, the Administrator, the Social Worker, and the Regional Director of Clinical Operations (RDCO) throughout the survey process and again at the exit conference on 11/20/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Activities of Daily Living is a term used in healthcare to refer to people's daily self-care activities. Health professionals often use a person's ability or inability to perform ADLs as a measurement...
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Activities of Daily Living is a term used in healthcare to refer to people's daily self-care activities. Health professionals often use a person's ability or inability to perform ADLs as a measurement of their functional status.
2. A record review was conducted on 10/03/23 at 01:10 PM. The resident was admitted with a diagnosis including a stroke and muscle weakness. In review of the resident's assessment indicated Resident #8 required with 2 personal physical to assist in mobility, transfer, dressing and toileting use.
On 10/04/23 at 12:59 PM during an interview with Occupational Therapist (OT) Staff #40 the resident required 2 persons to physically assist the resident within mobility and transfers and one person to assist for dressing and toileting use.
However, review of the resident care plan failed to show a plan of care for resident's assistance need of ADLs care.
Based on record review and interview it was determined that the facility failed to create a comprehensive care plan. This was found evident for 2 out of 13 (Resident #78 and #8) reviewed for care planning during an annual and complaint survey.
The findings include:
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
1. On 10/03/23 at 12:31 PM, the surveyor reviewed Resident #78's medical record. The review revealed that Resident #78 was admitted to the facility in early January of 2023 with a medial history of, post-traumatic stress disorder, and adjustment disorder with mixed anxiety and depressed mood.
On 11/17/23 at 12:01 PM the surveyor interviewed Regional Director of Clinical Operations Staff #39. During this interview the surveyor discussed concerns that Resident #78's psychological/psychiatry services may have been missed. Staff #39 stated she would look into the concern.
On 11/20/23 at 10:14 AM, the surveyor reviewed psych progress notes in the electronic medical record. Resident #78 was seen by psych on 2/6/23, 8/28/23, 10/13/23, 10/27/23, and 11/3/23. No documentation of being seen for 5 months between February through July.
On 11/20/23 at 10:25 AM, the surveyor reviewed the care plans for Resident #78. The review revealed a care plan for Resident #78 was created on 10/7/23 and stated, Resident #78 has a psychosocial well-being problem related to anxiety and post-traumatic stress disorder. An intervention stated, consult with psych (psychological/psychiatry) as indicated. This care plan was created 10 months after the Resident was admitted with this diagnosis.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
3. On 10/13/23 at 09:50 AM an interview was conducted with Resident #46, he/she complained why am I still here? Resident #46 met with the Social Worker Staff #14 for a safe discharge request and had n...
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3. On 10/13/23 at 09:50 AM an interview was conducted with Resident #46, he/she complained why am I still here? Resident #46 met with the Social Worker Staff #14 for a safe discharge request and had not heard back from her in terms of securing an outpatient dialysis center in his/her community for 3 times per week hemodialysis as soon as possible.
On 10/13/23 at 10:20 AM, in reviewing the social worker's notes, no documentation was found to support Resident #46's request was in progress.
During an interview on 10/13/23 at 10:39 AM with staff #14 revealed she was too busy and had not even started making any contact to outpatient dialysis centers near Resident #46's home.
On 10/19/23 at 12:11 PM an interview was conducted with Staff #14 and Social Worker's Assistant (Staff #64) revealed no progress was made to secure an outpatient dialysis center. Staff #64 stated she filled out the Metropolitan Transportation Authority (MTA) transportation ride request for to and from the future dialysis center only.
Metropolitan Transportation Authority (MTA) the public transport agency in the metropolitan areas.
Based on clinical record review, resident interview, and staff interview it was determined that the facility staff failed to ensure residents' discharge goals are evaluated and planned. This was evident for 3 (#71, #165, #46) of the 7 residents reviewed for the discharge process.
The findings include:
1. A review of Resident #71's clinical record on 10/31/23 as part of the investigation for intakes #MD00181160, #MD00183249, and #MD00190405 revealed that on 11/18/21 the Social Worker met with the resident to discuss progress in the facility as well as plans for discharge. The resident expressed a desire to return to the assisted living facility the resident occupied prior to admission to the nursing home. The Social Worker wrote This writer will follow up with this resident as needed.
On 4/17/23 at 4:12 PM the Social Worker (Staff #14) wrote a social services progress note. The note says, Resident's son has been visiting and care plan meeting is scheduled for 4/20/23 to discuss discharge plans.
The resident again expressed a desire to return to the community as expressed to the interdisciplinary team. This desire is reflected in the care plan goal to return to community setting such [as] an apartment in the community through [the] Waiver [program] upon discharge. The care plan was initiated on 6/4/23. A care plan goal was also created [Resident] will verbalize understanding of discharge plans and how to achieve goal. The goal was initiated on 6/4/23.
The resident was still in the facility during the recertification survey.
The Administrator was interviewed on 11/16/23 at 1:20 PM. We discussed that the resident has been requesting to be discharged since admission. Administrator could not explain why discharge has not happened. Mentioned there have been staffing changes over the years. He said he would review the resident's request for discharge with the interdisciplinary team.
2. A review of Resident #165's clinical record as part of the investigation for intake #MD00175238 was reviewed starting on 10/19/23.
The facility Social Worker, the Ombudsman, the resident and the resident's spouse met on 8/3/22. The reason for the meeting was the resident had been caught smoking in inappropriate places. Resident and spouse had both been informed of the facility's concern. Resident was reported as being impulsive. Options were discussed including but not limited to increasing smoking times. The resident was issued a 30-day involuntary discharge as the facility could not accommodate the resident's need to smoke when the resident wants to smoke. Resident requested going to a location that would allow more opportunities to smoke. Resident rejected the nicotine patch. Spouse agreed to call facilities close to them and the Social Worker would call facilities in the community. They agreed the resident needed close supervision by staff. Resident would not identify who supplied the smoking materials. Spouse is in agreement to transfer to facility offering more smoke options.
Social Worker wrote a note on 3/2/23 at 6:22 PM that she informed the spouse that the resident was still having smoking issues and that the case worker was working with spouse on discharge plans.
A discharge care plan meeting was held on 3/14/23 at 8:15 PM. Resident, spouse, friend of the resident, a Service Coordinator from the community waiver program, and facility staff attended. Administrator communicated the need for a safe discharge. Spouse communicated that arrangements for moving into an efficiency apartment that was already occupied were made. Administrator advised spouse to follow the correct steps to ensure a safe discharge for the resident. Social Worker tried to explain that it would be better to continue to keep resident on waiver where resident would be eligible for benefits. Spouse disagreed with the need to maintain resident on waiver program. Spouse was reminded it was still the facility responsibility to make sure resident is discharged to a safe location. Spouse disagreed and at this point informed team he/she was taking resident against medical advice (AMA). Spouse was made aware this would not be a safe discharge as nothing was in place such any medications or a wheelchair. Spouse left the facility with the resident.
A review of the facility AMA form revealed that the resident and spouse refused to follow waiver program process. Spouse wanted the resident to discharge to a studio apartment where the resident would not be on the lease.
It was not clear that the spouse and resident were thoroughly educated on the discharge process prior to the meeting.
The Social Worker (Staff #14) and the Administrator were interviewed on 10/19/2023 at 10:29 AM. If a resident smokes in the facility they are provided a behavioral contract. Activity puts them on contract. Smoking agreement if violated then the contract starts, and Activity enforces. Social work handles contracts for physical aggression. Rescinded 30-day notices are kept in business office. Administrator kept referring to their lawyers and that they did not like the language in the 30-day notice.
The Administrator was interviewed on 10/19/2023 at 1:30 PM. He said he checked with the business office and there was not a 30-day discharge notice issued for this resident. This surveyor said it is mentioned in the chart and he said he would check with the corporate lawyers.
The Administrator was interviewed on 10/19/2023 at 1:42 PM. He stated a 30-day was not given because the resident left AMA. This surveyor said the 30-day notice was given earlier in the resident's stay, and then I showed him where it was in a care plan. He replied that it might have been for a different resident. I read it to him to show it was not likely to be someone else. He replied understood. He also said he has a phone call into the lawyers.
The Administrator supplied on 10/20/23 at 11:34 AM an email chain. Resident appears to have been issued two 30-day discharges. Neither of the discharge notices were present in the chart. Email chain says the second 30-day discharge had been rescinded about the time of actual discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility staff failed to provide necessary activities of daily living (ADL) care based on the resident's level of daily l...
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Based on observation, interview, and record review, it was determined that the facility staff failed to provide necessary activities of daily living (ADL) care based on the resident's level of daily living needs. This was evident for 1 (Resident # 8) out of 6 residents reviewed for Activities of Daily Living (ADL) level of care.
The findings include:
Activities of Daily Living is a term used in healthcare to refer to people's daily self-care activities. Health professionals often use a person's ability or inability to perform ADLs as a measurement of their functional status.
On 09/28/23 at 11:20 AM an interview was conducted with Resident #8 after surveyor observed 2 Geriatric Nursing Assistant (GNA) staff #60 and staff #61 exited his/her room after the call light was turned off. Resident #8 stated he/she needed assistant to get up and asked for ADLs assistant, however, he/she was told that Nobody gets up before 12 noon. Surveyor observed for another 22 minutes outside of the room, staff did not return to provide ADLs assistance to get him/her up.
Geriatric Nursing Assistant (GNA) work directly with elderly patients to ensure their comfort and well-being.
A record review was conducted on 10/03/23 at 01:10 PM. Resident #8's assessment indicated he/she required 2 personal physical assistants in mobility, transfer, dressing and toileting use.
On 10/04/23 at 12:59 PM during an interview with Occupational Therapist (OT), Staff #40, confirmed that resident #8's recent OT assessment required two persons to physically assist with mobility and transfers and one person to assist for dressing and toileting use.
Occupational therapy (OT) is an allied health profession that involves the therapeutic use of everyday activities, or occupations, to treat the physical, mental, developmental, and emotional ailments that impact a patient's ability to perform daily tasks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities.
BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment.
On 09/28/23 at 8:15 AM, a review of Resident #59's medical record revealed a comprehensive MDS assessment dated [DATE] which showed a BIMS Assessment score of 00.
On 09/29/23 at 9:55 AM, an interview conducted with Resident #59's Personal Representative (PR) revealed that he/she met with the Activities Director twice to discuss the plan for Resident #59's activities since he/she was admitted to the facility two years ago. The PR stated that there had been no follow-up about Resident #59's activities plan from the Activities Department since then.
On 10/02/23 at 7:30 AM, a review of Resident #59's care plan dated 7/6/2023 revealed that he/she is dependent on staff for meeting emotional, intellectual, physical and social needs r/t cognitive deficits, disease process. Resident #59 had a goal that stated he/she should attend/participate in weekly activities 3-5 times a week. Additionally, interventions included in the care plan stated to provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Further review of Resident #59's medical record revealed no documentation to support that Resident #59 is engaged in an ongoing and individualized activities program.
On 10/02/23 on 9:47 AM, an interview with Activity Assistant #10 revealed that she was previously assigned to work with Resident #59 and was familiar with his/her activity preferences. The Activity Assistant #10 further stated that the Activity Director #9 was assigned to provide activities for the residents on the 4th floor which included Resident #59.
During an interview conducted on 10/04/23 at 8:46 AM, the Activity Director (AD) #9 stated he was assigned to conduct activities for the 4th floor, however he had not conducted any activities on the 4th floor since he began his employment at the facility in August 2023. The Activity Director (#9) further stated that he had not provided activities for Resident #59 and currently does not have a program in place for cognitively impaired residents but would like to develop a program.
Multiple observations conducted throughout the survey revealed Resident #59 wandering up and down the hallways. Resident #59 was not observed participating in structured, individual activities throughout the survey.
Based on observation, medical record review and interview, it was determined that the facility failed to provide on-going personalized activities for the residents. This was evident for 3 (Resident #4, #59, and #23) out of 5 residents reviewed for personalized activities.
The findings include:
1. Observation, on 09/28/23 at 12:20 PM, found that Resident#4 was lying in bed and did not respond to the surveyor but kept looking to the left side of the window.
Review, on 09/28/23 at 12:31 PM Resident #4's care plan indicated that group activities were not meaningful, based on his/her low cognitive baseline after a stroke and several chronic disease processes. The care plan included to offer one-to-one room visitations, alight with his/her previous interests of music and reading. Review of activity staff's documentation from the month of March to September 2023 revealed no one-to-one activity documentation was found.
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
On 09/29/23, an observation was made from 10:12 AM until 11:10 AM, Resident #4 was observed a second time in his/her room. The resident, who was sitting in a wheelchair and looking at the walls. There was no evidence that activity staff provided a one-to-one adequate provision of personalized activities.
During the interview, on 10/03/23 at 02:18 PM, Activity Director (Staff #9) stated if residents could not participate in group activities, then one-to-one was offered in following: music, reading newspaper, storytelling, or hand massage. Activity Assistant (Staff #10) stated that she was pushing her activity cart to residents' rooms for lower cognitive residents at least twice per week. However, she did not document any of her one-to-one activities with residents including Resident #4.
This resident is confined to his/her room; both activity staff were unable to provide any on-going personalized activities documentation such as one-to-one room visits.
3. On 09/28/2023 at 1:58 PM, Resident #23, a cognitively intact resident, was observed lying awake in bed. Resident #23 was subsequently interviewed, and he/she said that facility staff do not bring him/her activities to do, nor do they engage with them in 1:1 activities.
A record review revealed that in the activities assessment completed on 07/07/2023, facility staff wrote that Resident #23 prefers 1:1 room visits.
On 10/03/2023 at 9:45 AM, Resident #23 was observed lying awake in bed, not engaged in activities.
On 10/04/2023 at 9:34 AM, Staff #9, the Activities Director commented that while his staff engaged residents in 1:1 activities, they were not recording that they were doing them. He could provide no evidence that his staff engaged Resident #23 in 1:1 activities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to provide appropriate oxygen t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to provide appropriate oxygen therapy equipment. This was found to be evident for 1 (# 416) out of 1 resident observed on oxygen therapy.
The findings include:
During an observation on [DATE] at 08:05 AM, the surveyor observed Resident # 416's oxygen cart did not have a handle and the tubing was dated [DATE].
On [DATE] 08:40 AM, the surveyor observed that Resident # 416's oxygen cart did not have a handle and the oxygen tubing was dated [DATE]. Resident # 416 told the surveyor that the tank was empty and without a handle the tank was slippery when trying to move it.
During an interview on [DATE] at 08:48 AM, the surveyor asked LPN # 21 the process for changing the oxygen tubing. She replied that the tubing should be changed and labeled every night by the night shift and that Resident # 416 uses oxygen as needed. The surveyor told her Resident # 416 stated that the tank was empty. She replied she would check the tank, change it if empty and change the oxygen tubing. I spoke to her of the concern that the O2 cart did not have a handle and she said it would be replaced.
On [DATE] at 09:15 AM, the Director of Nursing was interviewed regarding the concerns about the missing hand grip on the oxygen cart and the expired oxygen tubing. She stated tubing should be changed every 7 days and staff would be educated.
On [DATE] at 11:32 AM, the surveyor reviewed the facility Oxygen Administration Policy implemented on [DATE] that read to change oxygen delivery devices every 72 hours or per facility policy and as needed for soil or decontamination. Keep delivery devices covered in plastic when not in use. Review of the Treatment Administration Record revealed orders for oxygen use as needed and tubing changes every 7 days.
The surveyor observed that Resident # 416 had a new oxygen concentrator and tubing covered in a plastic bag on [DATE] on 08:00 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that the facility failed to develop and implement a process to determine if residents with a history of trauma received the appropriate trauma in...
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Based on record review and interview it was determined that the facility failed to develop and implement a process to determine if residents with a history of trauma received the appropriate trauma informed care. This was evident for 1 (#568) of 1 resident reviewed for trauma informed care.
The findings include:
A medical record review for Resident #568 on 2/28/24 at 9:17 AM revealed the Attending Physician's notes for a visit on 12/31/23 that documented the resident had a history of post-traumatic stress disorder. Further review revealed no evidence that an assessment or care plan had been completed to ensure the resident received trauma informed care.
An interview with Social Services Staff #24 on 3/1/24 at 10:34 AM revealed she was unaware of a trauma screen being conducted on residents at the facility.
An interview with the Director of Nursing (DON) on 3/4/24 at 3:47 PM revealed that the facility had no process in place to screen residents for a history of trauma in order to develop and implement a plan of care addressing the trauma.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with staff, and review of medical records, it was determined that the facility failed to appropriately treat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with staff, and review of medical records, it was determined that the facility failed to appropriately treat a resident diagnosed with a mental disorder. This was evident of 2 of 4 residents (Resident #115 & #78) reviewed for mental health services during the annual survey.
The findings include:
The surveyor reviewed Resident #115's medical records on [DATE] at 2:03 PM. The review revealed that Resident #115 was admitted to the facility in early January of 2022 and had a past medical history of schizophrenia.
Further review of the record revealed a progress note from Psychiatrist Staff #54 (a physician that specializes in mental health) on [DATE]. The progress notes stated that Staff #54 was asked to see Resident #115 due to agitation, depression and to evaluate medications. In the note Staff #54 recommended beginning Prolixin 2.5mg in the morning and 5mg before bed for schizophrenia.
On [DATE] at 11:45 AM, the surveyor reviewed a progress note written on [DATE] by Resident #115's primary provider, Staff #51. The progress note stated he saw the resident and reviewed the psychiatry's recommendation. Staff #51 wrote for Resident #115 to receive an electrocardiogram (EKG) (a test to evaluate the heart rhythm) on Tuesday and if normal consider starting Prolixin (also known as Fluphenazine).
Further review of the progress notes reveal a note written on [DATE] by the former Administrator, Staff #52. The note stated that Resident #115 was threatening a female resident in the lobby. The note also stated Resident #115 then threatened a male resident. Staff #52's note further stated Resident #115 pushed the Director of Nursing (DON) into the wall and told her that his/her gang will come to kill her. An Emergency Petition (EP) was sought from the Psychiatry provider and the resident was taken to the hospital.
On [DATE] at 11:45 AM, the surveyor reviewed Medication Administration Record (MAR) for Resident #115 for August and [DATE]. The review revealed that Resident #115 had an EKG documented as completed on [DATE]th 2022. On [DATE] an order was written for Fluphenazine once per day for agitation. This was the first time the order was written for even after the primary physician had written on [DATE] that Resident #115 could start on Fluphenazine after the evaluation of the EKG.
The surveyor reviewed the orders for Resident #115 and discovered that Prolixin was first ordered after Resident #115 returned from his/her hospital stay and not when recommended two weeks prior.
The facility failed to administer psychological medications recommended by Staff #54.
2) On [DATE] at 12:31 PM, the surveyor reviewed Resident #78's medical record. The review revealed that Resident #78 was admitted to the facility in early January of 2023 with a medical history of, post-traumatic stress disorder, and adjustment disorder with mixed anxiety and depressed mood.
On [DATE] at 00 AM, the surveyor reviewed Resident #78's orders. Resident #78 had an order for psychology/psychiatry (psych) to consult and treat as needed written on [DATE], [DATE], [DATE], & [DATE] and on [DATE], [DATE], [DATE] a psych consult was ordered related to specific behaviors.
On [DATE] at 10:14 AM, the surveyor reviewed psych progress notes in the electronic medical record. Resident #78 was seen by psych on [DATE], [DATE], [DATE], [DATE], and [DATE].
Further review of the progress note written on [DATE] by psych Nurse Practitioner (NP) Staff #55 stated, Refer for individual therapy pending insurance approval.
On [DATE] at 9:50 AM, the surveyor reviewed progress notes written by Physician Assistant (PA) Staff #56. On [DATE] Staff #56 wrote a note and documented, Resident #78 reported his/her anxiety had not been controlled since Klonopin (a medication to help with anxiety) expired. Staff #56 wrote she would restart Klonopin and for a psych consult for anxiety. Following anxiety she stated a plan for depression and post-traumatic stress disorder as continue medications and psych consult.
On [DATE] at 10:25 AM, the surveyor reviewed the care plans for Resident #78. The review revealed a care plan for Resident #78 stating, Resident has potential to be verbally aggressive related to ineffective coping skills created on [DATE]. One of the interventions was for psychiatric/psychogeriatric to be consulted as indicated. However, the most recent consult completed after this was [DATE].
On [DATE] at 12:01 PM the surveyor interviewed Regional Director of Clinical Operations Staff #39. During this interview Staff #39 was asked if Resident #78 received the psych services that were recommended and ordered, such as individual psychotherapy. Staff #39 stated the facility consults an outside service and they have the ability to provide all psychosocial services needed. She further stated every Resident in the building has an order to have a psych consultation. The psych services professionals come weekly and check a book on the floor to help evaluate who they need to see. Staff #39 stated, the facility is ultimately responsible to make sure these services are provided.
On [DATE] 1:18 PM, the surveyor conducted a phone interview with the manager of the consulting psych services company, Staff #92. During the interview Staff #92 stated the process for offering psych services starts with a referral from the facility and once the Resident is seen they are placed on a working list. She further stated, there is a list of residents that need to be seen on the unit at the facility and providers check the list each time. She further stated, that if referrals are needed within our service the company handles referrals internally and will provide the services. Staff #92 was asked if Resident #78 received individualized psychotherapy per recommendations of Staff #56 with the instructions, per insurance approval. Staff #92 stated she would look into that and would follow up.
On [DATE] at 3:16 PM, the surveyor conducted a follow-up phone interview with Staff #92. During the interview Staff #92 stated that Resident #78's individual psychotherapy would have been covered by insurance, however it was not communicated correctly in the system and Resident #78 did not receive those services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to ensure social work assisted a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to ensure social work assisted a resident with their needs. This was evident for 1 (#385) out of 140 residents in the survey sample.
The findings are:
A review of Resident #385's clinical record as part of the investigation into intake #MD00180949 was started on 10/12/23. The resident was admitted on [DATE] and discharged on 11/19/22. Review revealed that there were two social work notes in the clinical record, one on 3/23/22 and the other on 8/2/22.
The Nurse Practitioner wrote a progress note on 8/16/22 at 9:31 AM stating that the resident wanted to be discharged home. The resident denied any medical complaints and believed discharge was appropriate. There were no social work notes or evaluations found in the clinical record even after the resident requested to be discharged home.
The Social Services Director (Staff #14) was interviewed by survey team members on 10/13/23 at 10:43 AM. She said she started working at the facility on 9/6/23. She said there wasn't an active social work department when she started. The administrator caught her up on the residents that needed immediate attention. They had someone come in from another facility to come in and help out. She said when there wasn't a social worker here then they had someone come in to help with the discharge planning, but she did not believe they were completing social histories. They were not doing care plan meetings.
The Administrator was informed of the social work concerns on 10/20/23 at 2:17 PM. He said he would look into it.
Evidence of social worker assessments and discharge planning for this resident were not provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of medical records, medication monitoring/control records and interview with staff, it was determined the facility failed to implement a system to consistently and accurately reconcile...
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Based on review of medical records, medication monitoring/control records and interview with staff, it was determined the facility failed to implement a system to consistently and accurately reconcile controlled medications. This was evident for 2 out of 6 narcotic log binders reviewed during the recertification survey.
The findings include:
On 10/12/2023 at 11:30 AM surveyors and Staff #25 reviewed the 1st of 2 narcotic binders on the unit which revealed a medication monitoring/control record for Resident #27. The record showed a medication order written by Physician, Staff #50, that read, {medication} 5 mg (milligram) tablet, Give one tablet by mouth every 12 hours as needed for pain. During review of Resident #27's medication monitoring/control record, Staff #25 and the surveyor identified a missing staff signature from the administration of one 5 mg tablet of {medication} on 10/7/2023 at 1:00 AM.
Review of the 2nd of the two narcotic log binders on the 3rd floor in the presence of Staff #25, revealed a medication/control record for Resident #63. The record showed a medication order written by Staff #50 that read, [medication] 5 mg tablet, Give two tablets by mouth every four hours as needed for pain (pain scale 7-10). Also noted on the record, for date 10/10/2023 @ 6:30 PM, was the On Hand amount written as 16, and the Amount Given written as 2, then the Remaining Amount written as 16. Staff #25 confirmed the signature for this miscount was documented by an agency nurse, Staff #102.
During interview with Staff #25, he confirmed that incorrect documentation on any of the resident's medication monitoring/control records was to be identified at shift change between the off-going nurse and the incoming nurse during the medication count which requires signatures from both nurses. Staff #25 confirmed that the Unit Manager was responsible for the daily review of the narcotic binders on the unit.
Surveyor and Staff #25 reviewed Resident # 88's medication monitoring/control record dated as received on 9/30/2023. The review revealed a missing signature for the medication administered on 10/5/2023 at 9:30 AM. Staff #25 confirmed that he will bring this to the attention of the Unit Manager and the expectation is that all nurses who administer controlled medications are to sign for each dose administered at the time the medication is administered.
Also, during review of the 2nd narcotic binder on the unit, surveyors and Staff #25 identified a missing staff signature from an opioid administered to Resident #27 on 10/7/2023 at 1 AM. Again, Staff #25 confirmed that the expectation is that all nurses who administer controlled medications are to sign for each dose administered at the time the medication is administered.
These concerns were made known to the interim Director of Nursing (DON) on 10/12/2023, and to the Regional Director of Clinical Operations (RDCO) and Administrator throughout the survey and again at survey exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to prescribe a therapeutic diet for a resident. This was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to prescribe a therapeutic diet for a resident. This was based on 1 (# 124) out of 1 resident reviewed for correct dietary orders.
The findings include:
On 10/18/2023 at 9:55 AM, the surveyor reviewed a complaint dated 9/27/21 on behalf of Resident #124. The complainant alleged the family had to have food delivered because the facility did not serve the resident a therapeutic diet. Although the resident was admitted on [DATE], according to the record review, the facility did not initiate a cardiac diet until 9/28/21 after Resident #124 requested a dietary consult.
The surveyor's review of the Nursing admission Assessment on 10/19/2023 at 8:11 AM, dietary requirements read: Cardiac Consistent Carb Diabetic for Resident #124.
During an interview on 10/19/2023 at 8:25 AM with the Regional Director of Clinical Operations (RDCO), the surveyor asked what the process was for ordering a therapeutic diet. She stated the admitting nurse sends an order to dietary with the therapeutic diet request. When asked if she could find a therapeutic diet order from Resident # 124's admission date, she stated she would see if she could locate it.
On 10/20/2023 at 9:30 AM during an interview with RDCO, the surveyor asked if there was any additional information regarding the admission diet orders for Resident #124. She stated that she was not able to find an admitting diet order and she did not believe there was any way to check what diet was served at that time, but she would consult the Regional Dietary Manager and let the surveyor know if anything was found. Nothing was produced prior to the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interviews, it was determined that the facility failed to maintain the outdoor garbage storage area in a manner to prevent the harborage and feeding of pests.
The findings in...
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Based on observation and interviews, it was determined that the facility failed to maintain the outdoor garbage storage area in a manner to prevent the harborage and feeding of pests.
The findings include:
During an outside tour of the facility on 10/04/23 at 11:10 AM, the Surveyor and DM #94 observed debris scattered around the dumpster area. The debris included a peanut butter and jelly sandwich and disposable cups and food containers. The garbage bin close to the basement exit door was full to the top with trash items.
In an interview conducted on 10/04/2023 at 11:17 AM, DM #94 confirmed that the expectation for trash disposable was that all trash is to be contained inside of the dumpster to avoid the potential of attracting rodents and stated that scattered debris and all other trash would be disposed of immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to initiate a Quality Assurance and Performance Improvement (QAPI) plan. This was evident for 1 out of 1 QAPI plan reviewed during the annual ...
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Based on record review and interview, the facility failed to initiate a Quality Assurance and Performance Improvement (QAPI) plan. This was evident for 1 out of 1 QAPI plan reviewed during the annual survey.
The findings include:
The Centers for Medicare and Medicaid Services (CMS), defines Quality Assurance (QA) and Performance Improvement (PI) as a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem-solving.
On 11/8/23 at 09:15 AM, the surveyor reviewed the 2023 Quality Assurance and Performance Improvement (QAPI) Plan. Under the Vision, Mission, Purpose and Guiding Principles statements, the facility had the examples that were provided on the template. For the section titled QAPI Goals the Example Goals are listed with [include date here], not a facility-initiated goal date. In the Communications section the examples from the template were listed. The Establishment of the QAPI Plan section read, This plan was established on [insert date the plan was created]. The revision dates page stated the plan was revised on 10/14/22 and 7/27/23. It appeared the only alteration to the template was to add, Carroll Park Healthcare to the title page.
During an interview on 11/15/23 at 11:30 AM, the Administrator was shown the current QAPI plan by the surveyor with the template examples still in place. He confirmed that it was the current QAPI plan. When shown that the QAPI plan did not have facility specific concerns and the template examples were all in use, he stated it is a template, I understand the concern. We have not had a QAPI person to update the plan. It will be a priority for our new Assistant Director of Nursing that we just hired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Personal Protective Equipment (PPE) is equipment worn to minimize exposure to hazards that cause serious workplace injuries a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Personal Protective Equipment (PPE) is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.
On 10/03/23 at 12:00 PM, an observation was made outside of room [ROOM NUMBER]. A wound treatment cart was located in front of the room. On the door, surveyors noted a sign that indicated PPEs were to be worn in the room when providing care. A PPE cart was located on the floor to the right side of the room [ROOM NUMBER]'s. Further observation of the cart revealed that there were no PPE gowns in it. At 12:05 PM, Nurse Practitioner (Staff #30), and wound nurse (Staff #31) came out of the room and were interviewed.
During the interview, Staff #30 stated that she requested PPE gowns earlier from the central supply person (Staff #33) and was told by her that she already filled all the PPE carts that day. Staff #30 added that this was her second attempt to change Resident #61's multiple wounds dressing, so she and Staff #31 decided to attend the wound care without wearing the proper PPE gowns on.
Observations on the second-floor unit 10/03/23 at 12:42 PM revealed that the isolation carts that were outside of isolation residents' rooms #205, #208, #209, #210, #212, and #217 all failed to have proper PPEs stocked inside.
An interview on 10/05/23 at 08:36 AM with Staff #33, revealed she was responsible for the facility's PPE supplies on the unit. During the week, at 6 AM she would stock the units' PPE carts for the day and staff would inform her whenever their unit's carts needed restocking. However, she never received calls from the second nor the third floors' staff regarding the floors' PPEs shortage. Following Staff #33 to the facility's PPEs storage room revealed plenty of PPEs supplies are in stock but failed to distribute to all PPE carts.
2. On 10/10/23 at 10:36 AM, the surveyor conducted an interview with Resident #36. During this interview Resident #36 stated he/she was just recently placed in isolation and that the facility removed his/her roommate from the room.
On 10/11/23 at 11:32 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the NHA explained that the Maryland Department of Health (MDH) contacted the facility about Resident #36 and reported that they had identified Resident #36 as having Carbapenamese-producing Carabapement resistant Enterobacerales (CP-CRE). (CP-CRE is a subset of CRE's and a concern for a drug-resistant bacteria) He further stated that the facility took the precautions that the MDH had recommended.
On 10/11/23 at 12:32 PM, the surveyor interviewed Physician Staff #50. During this interview Staff #50 stated if a Resident was identified as having CRE they should be on contact precautions. When the surveyor asked if they could be on enhanced barrier precautions, Staff #50 stated, she was not sure.
On 10/12/23 at 10:48 AM, the surveyor conducted an interview with Regional Director of Clinical Operations Staff #39 (also acting as the Infection Preventionist for the facility) During this interview Staff #39 confirmed that Resident #39 was on contact precautions.
On 10/13/23 at 1:50 PM, the surveyor reviewed the orders for Resident #36. An order was written on 10/5/23 by Staff #50 for contact precautions.
On 10/17/23 at 8:55 AM, the surveyor observed both a contact isolation sign as well as an enhanced barrier precautions sign up on Resident #36's door. The instructions were different. In the contact instructions both, a gown and gloves were required before entering the room. For Enhanced barrier precautions the instruction required a gown and gloves only when staff were performing high-contact resident care activities. The activities were listed on the sign. In both the contact and enhanced barrier precautions the gown and gloves were instructed to be utilized for one Resident and to be discharged and after use.
On 10/17/23 at 9:15 AM, the surveyor observed Licensed Practical Nurse (LPN) Staff #23 walk into Resident #39's room with a gown and gloves on. The surveyor observed Staff #23 give Resident #36 his/her medications. After administering the medications Resident #36 asked Staff #23 to remove his/her breakfast tray from the room. Staff #23 took the tray, walked into the hallway with her gown and gloves on and placed the tray on a storage container located in the hallway, just outside Resident #36's room, which was holding isolation supplies.
After this observation the surveyor interviewed Staff #23. During this interview Staff #23 stated she realized after walking out of Resident #36's room that she should have removed her gown and gloves. She also confirmed the food tray should not be stored on the isolation supply storage bin. Staff #23 picked up the tray and took the tray away.
On 10/17/23 at 9:22 AM, the surveyor conducted an interview with the 2nd floor Unit Manger Staff #32. During this interview Staff #32 clarified that Resident #36 should be on contact precautions and not have both signs up. Staff #32 was informed of the observations made of Staff #23. Staff #32 stated he will need to do some education on contact precautions with his staff.
On 10/19/23 at 7:48 AM, the surveyor made an observation and noted Resident #36 had only the contact precautions sign on the door.
Based on observations and staff interviews, it was determined that the facility failed to ensure that clean linen was protected from contamination, to ensure isolation carts contained Personal Protective Equipment (PPE), and to maintain effective infection prevention practices. This was evident for 1 (3rd floor) of 3 floors observed for the handling of linens, for 7 out of 7 isolation carts observed, and for 1 of 3 random observations during an annual and complaint survey.
The findings include:
1. On 09/28/2023 at 8:11 AM, an interview was conducted with Staff #2, a Geriatric Nursing Assistant. She said that the door to the 3rd floor linen cabinet was broken. She stated It gets contaminated. Residents reach in there with their dirty hands and then we have to touch the linens. At 8:15 AM the Surveyor observed that the linen cabinet was missing a door leaving clean linen exposed.
On 9/28/2023 at 10:34 AM, this finding was verified by Staff #3, the Unit Manager, who said that he did not know how long the door had been broken for.
On 10/03/2023 at 9:15 AM, an observation of the 3rd floor linen closet revealed that it was still missing a door and the clean linen was exposed.
On 10/03/2023 at 10:41 AM, the Director of Nursing was reminded that the linen closet finding had been brought to the attention of the Unit Manager last week.
On 10/4/2023 at 9:07 AM, an observation of the 3rd floor linen cart revealed it was still missing a door and the clean linen was exposed. At 10:30 AM, the Nursing Home Administrator was made aware the door was still broken. He said they ordered a new cabinet.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on clinical record review and family interview it was determined that the facility failed to ensure that a resident had access to a working adaptive device. This was evident for 1 (#121) out of ...
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Based on clinical record review and family interview it was determined that the facility failed to ensure that a resident had access to a working adaptive device. This was evident for 1 (#121) out of the 140 residents that are part of the survey sample.
The findings include:
Resident #121's clinical record was reviewed starting on 10/30/23 as part of the investigation into intake #MD00189052.
A nurse wrote in a nursing progress note on 1/23/23 that the resident had a follow up Angiogram [scan that shows blood flow through the circulatory system] appointment today (1/23/23) at [name of hospital]. Was unable to go to the appointment because we are unable to provide ambulance transportation at this time, [the resident] transfers using a Hoyer [a device used to lift a person off of a bed] which is also broken. The appointment was rescheduled.
The resident's spouse was interviewed on 11/6/23 at 2:28 PM. Spouse said the resident needed the Hoyer lift to get out of bed.
The facility Administration was informed of the results at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility to ensure that Agency Staff received facility training prior to working. This was found to be evident for 1 (# 62) out of 1 Agency Staff interviewed r...
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Based on interview and record review the facility to ensure that Agency Staff received facility training prior to working. This was found to be evident for 1 (# 62) out of 1 Agency Staff interviewed regarding facility training.
The findings include:
The surveyor asked Agency Geriatric Nursing Assistant (GNA) # 62 on 10/25/2023 at 9:46 AM, who was sitting at the 4th floor nurses station what she would do if the shower wasn't working. She stated, I would tell the nurse. I am agency this is my second time here. When asked if she received training by the facility she replied, I have not had training by this facility. This is my second day here.
On 10/25/2023 at 10:11 AM, Regional Director of Clinical Operations was interviewed about the process of Agency training prior to working on the floor. She stated she would call the Human Resources (HR) Director to speak to the surveyor but everyone should be trained prior to working on the floor.
During an interview, on 10/25/2023 10:30 AM, the HR Director # 8 stated the agency training process has been in place for 2 months. As the HR Director I am responsible to ensure training is completed. The Agency GNA # 62 you spoke with is going through the training binder right now. The process to inform the Agency staff is the scheduler informs the staff that they need to talk to the nurse manager when they arrive on the floor to get the training binder. I created this process because I saw the need. I will audit this process in the future. I will follow up with the agencies and scheduler to review the process and educate. She further stated that Agency staff need to repeat the education annually and she tracks it with the sign in sheet located in the training binders and showed the sign in sheets to the surveyor.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on reviews of a facility reported incident, a nursing assistant's employee files, and staff interview, it was determined that the facility failed to confirm an agency nursing assistant had abuse...
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Based on reviews of a facility reported incident, a nursing assistant's employee files, and staff interview, it was determined that the facility failed to confirm an agency nursing assistant had abuse, neglect, exploitation, and misappropriation of resident property education before allowing the agency nursing assistant to work with residents in the facility. This was evident for 1 of 12 nursing assistants reviewed during an annual recertification survey.
The findings include:
Review of facility reported incident #MD00184909 on 11/01/23 revealed details were staff member #87 was asked by Resident #144 to go buy him some cigarettes on 10/22/22. In addition to buying the smoking materials with Resident #144's bank card, staff member #87 also withdrew an additional $40 dollars cash without Resident #144's permission.
In an interview with the facility Director of Human Resources (HR) on 11/14/23 at 3:15 PM, the HR director was unable to produce documentation that staff member #87 received education regarding resident rights and abuse before being allowed to work with residents.
Cross Reference F 602
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that the facility failed to facilitate care plan meetings for resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that the facility failed to facilitate care plan meetings for residents. This was evident for 5 residents, (#59, #159, #463, #465 and #467) of 5 residents reviewed for care planning.
The findings include:
During an interview conducted on 09/27/23 at 10:06 AM, Resident #59's Personal Representative (PR) stated that there have only been 2 care plan meetings held since Resident #59 was admitted to the facility on [DATE]. Resident #59's PR further stated that she does not know who the current Director of Nursing or Social Worker is and has not been contacted about care plan meetings for Resident #59.
On 09/27/23 at 10:37 AM, a review of Resident # 59's medical record revealed no evidence that a care plan meeting was conducted.
During an interview conducted on 09/28/23 at 07:50 AM, Resident #463 stated that he/she did not participate in the care plan meeting and only knows about his physical therapy (PT) treatment.
On 09/28/23 at 8:37 AM, a review of Resident # 463's medical record revealed no evidence that a care plan meeting was conducted.
During an interview conducted on 09/29/23 at 07:27 AM, Resident #467 stated, I don't think I've had a care plan meeting yet. That would help me get myself together.
On 09/29/23 at 9:25 AM, a review of Resident # 463's medical record revealed no evidence that a care plan meeting was conducted.
During an interview conducted on 10/05/23 at 10:39 AM, Social Worker #14 stated that care plan meetings are scheduled 7 days after admission, quarterly, and when there is a significant change. Social Worker #14 stated that prior to September 2023, care plan meeting notifications were verbal, however, the new process requires the facility to send a letter to the resident and/or representative. Social Worker #14 further stated that she has not scheduled care plan meetings for Resident #59, #463, #465 and #467.
On 11/02/2023 at 12:45 PM, a review of Resident #159's medical record revealed no evidence that a care plan meeting was conducted.
During an interview conducted on 11/03/2023 at 11:20 AM, the Regional Director (#39) confirmed that care plan meeting notes were not found in Resident #159's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on interviews and record review it was determined that the facility failed to inform residents of their right to formulate advanced directives. This was found evident for 5 out of 7 (Resident #5...
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Based on interviews and record review it was determined that the facility failed to inform residents of their right to formulate advanced directives. This was found evident for 5 out of 7 (Resident #55, #22, #15, #67, and #27) residents reviewed for advanced directives during an annual and complaint survey.
The findings include:
1. On 10/3/23 at 11:32 AM, the surveyor conducted a medical record review for Resident #55. The review revealed that Resident #55's initial admission to the facility was in January of 2022 and the most recent admission was in April of 2023.
Further review of the medical record revealed that Resident #55 had no advanced directive in his/her medical record and no documentation that he/she was offered to create one.
On 10/3/23 at 1:28 PM, the surveyor conducted an interview with the Social Service Director Staff #14. During this interview Staff #14 stated, if a resident comes into the facility and does not have an advanced directive, she does not ask them if they would like to formulate one. Staff #14 further stated, only if a resident requests to formulate an advanced directive then she would print advanced directive forms and give them to the resident.
On 10/3/23 at 2:14 PM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). The Administrator agreed that residents who had not previously created advanced directives, were not given the opportunity to formulate them on admission.
2. On 10/2/23 at 12:37 PM, the surveyor reviewed Resident # 22's medical record. The review revealed that Resident #22 was admitted to the facility in early 2023.
Further review revealed no documentation that Resident #22 had an advanced directive in his/her medical record and no documentation that he/she was offered to create one.
On 10/3/23 at 1:28 PM, the surveyor conducted an interview with the Social Service Director Staff #14. During this interview Staff #14 stated, if a resident comes into the facility and does not have an advanced directive she does not ask them if they would like to formulate one. Staff #14 further stated, only if a resident requests to formulate an advanced directive then she would print advanced directive forms and give them to the resident.
On 10/3/23 at 2:14 PM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). The Administrator agreed that residents who had not previously created advanced directives, were not given the opportunity to formulate them on admission.
5. A Maryland Order for Life Sustaining Treatment (MOLST) form is a two-page order form about cardiopulmonary resuscitation and other medical treatments. On 09/29/2023 at 8:00AM, a review of Resident #27's paper chart revealed that the resident had no MOLST in his/her chart.
On 09/29/2023 at 11:00 AM, a review of Resident #27's electronic medical record revealed that there was no current order or code status indicator in the electronic medical record.
On 9/29/2023 at 1:00 PM, Staff #3, a Unit Manager, and Staff #24, a Licensed Practical Nurse, verified the findings. Staff #3 stated that there was an issue with the doctor signing the MOLST. He said that he understands why it's a problem, that if there was an emergency staff would not know his/her code status.
On 10/02/2023 at 10:00 AM, a record review revealed that there was still no MOLST in the paper chart or code status order in the electronic medical record.
On 10/02/2023 at 10:10 AM, an interview with Staff #14, from the social work department, revealed that she kept a book of resident MOLST forms. She verified that she did not have a MOLST form for Resident #27 in the book.
On 10/02/2023 at 10:15 AM, this finding was brought to the Nursing Home Administrator who acknowledged it's an issue.
On 10/02/2023, the facility staff completed a MOLST form with Resident #27 and a full code order was entered into the electronic medical record.
3. A review of Resident #15's clinical record on 9/29/23 at 9:53 AM revealed that he/she was admitted without an Advance Directive and was not offered an opportunity to create one.
Staff #14 was interviewed on 10/3/23 at 1:29 PM. She said when residents are admitted she will forward a copy of an Advance Directive to nursing if provided to her. The copy goes on the chart and she gets a copy. The social work consultant does not help with creating an Advance Directive. If a resident says no but does not request to formulate an Advance Directive then she does not help to initiate it.
4. A review of Resident #67's clinical record on 9/28/23 at 8:52 AM revealed that he/she was admitted without an Advance Directive and was not offered an opportunity to create one.
Staff #14 was interviewed on 10/3/23 at 1:29 PM. She said when residents are admitted she will forward a copy of an Advance Directive to nursing if provided to her. The copy goes on the chart and she gets a copy. The social work consultant does not help with creating an Advance Directive. If a resident says no but does not request to formulate an Advance Directive then she does not help to initiate it.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
3. Facility self-report file review on 10/16/23 at 11:01 AM revealed on 9/14/2023 approximately 5 PM, facility staff at the nurse's station on the 3rd floor were made aware of an abuse incident involv...
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3. Facility self-report file review on 10/16/23 at 11:01 AM revealed on 9/14/2023 approximately 5 PM, facility staff at the nurse's station on the 3rd floor were made aware of an abuse incident involving Resident #90. However, the State Agency was not notified until 9/14/2023 at 9:39 PM, more than 4 hours later.
Nursing home facilities are required to report allegations of abuse to the State Agency no later than 2 hours after the abuse allegation was made or was observed. This did not occur.
2. On 10/2/23 at 12:37 PM, the surveyor reviewed Resident #22's medical record. The review revealed that Resident #22 was admitted to the facility in early 2023.
Further reviewed revealed Resident #22 had a scheduled appointment at an outside facility on 6/1/23 and left with transportation at 11:30 AM.
The surveyor reviewed a progress note written by Social Services Staff #14 on 6/1/23 that stated Staff #14 received a call from an outside provider regarding Resident #22. The caller informed Staff #14 that Resident #22 did not want to return to the facility and felt like he/she was being mistreated at the facility.
On 10/3/23 at 2:06 PM, an interview with the Nursing Home Administrator (NHA) was conducted. The NHA stated he did not report this allegation.
Based on clinical record review, review of facility abuse investigations, and staff interview it was determined that the facility staff failed to ensure allegations of abuse were reported to the state agency. This was evident for 3 (#150, #22, and #90) out of 30 residents reviewed for abuse.
The findings are:
1. A review of intake MD00188656 was started on 10/20/23 at 11:11 AM. A review of the nursing progress notes dated 1/31/23 at 2:59 PM revealed that Resident #150 alleged that someone struck him/her really hard in the face during the middle of the night and returned later to kiss him/her on the cheek. The resident later alleged a dog tried to bite him/her.
A review of the facility investigation revealed that a nurse (Staff #21) was informed on 1/31/23 of the allegation by the resident. Staff #21 said she observed no signs or symptoms of injury. She said she then told the unit manager (Staff #86) the same day. Further review revealed that the incident was not reported to the state agency until 2/5/23.
This surveyor interviewed the Administrator on 10/20/23 at 10:54 AM. The incident was summarized and explained to the Administrator. The resident alleged that they were slapped on 1/31/23. The resident told the nurse who then passed the allegation to the unit manager. The allegation was not reported to the state agency until 2/5/23. He acknowledged the details and showed a printout of the email confirmations of their self-report. The printout showed that both the initial and final reports were emailed on 2/5/23.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
6. On 10/2/23 at 12:37 PM, the surveyor reviewed Resident #22's medical record. The review revealed that Resident #22 was admitted to the facility in early 2023.
Further reviewed revealed Resident #2...
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6. On 10/2/23 at 12:37 PM, the surveyor reviewed Resident #22's medical record. The review revealed that Resident #22 was admitted to the facility in early 2023.
Further reviewed revealed Resident #22 had a scheduled appointment at an outside facility on 6/1/23 and left with transportation at 11:30 AM.
The surveyor reviewed a progress note written by Social Services Staff #14 on 6/1/23 that stated Staff #14 received a call from an outside provider regarding Resident #22. The caller informed Staff #14 that he/she did not want to return to the facility and felt like he/she was being mistreated at the facility.
On 10/3/23 at 9:39 AM, the surveyor conducted an interview with Resident #22. During the interview Resident #22 stated he/she had received better care at a different facility but had no personal concerns now. Resident #22 stated when he/she returned to the facility the facility did not interview or follow up with him/her as to why he/she did not want to return.
On 10/3/23 at 1:45 PM, the surveyor interviewed Staff #14. During this interview Staff #14 described the steps taken when she is aware that a resident is reporting being mistreated. Staff #14 stated she would let the Administrator aware, separate and protect a resident from the perpetrator and an investigation would be started. Staff #14 recalled getting the phone call from the outside provider about Resident #22 and remembers she notified the Nursing Home Administrator NHA) and Director of Nursing (DON). She reports thinking they did an investigation.
On 10/3/23 at 2:06 PM, an interview with the NHA was conducted. The NHA stated he did not report this case or do a formal investigation. The NHA stated he remembered he reached out to Resident #22's family member to understand why Resident #22 did not want to return and the family member stated the resident felt like he/she was being treated like a child. The NHA confirmed he never followed up or investigated the concern of mistreatment Resident #22 had when he/she returned to the facility.
7. On 10/3/23 at 2:00 PM, the surveyor requested the facility's investigation report from an alleged incident of abuse the facility reported on 5/13/22.
On 10/18/23 at 9:44 AM, the surveyor followed up with the Nursing Home Administrator (NHA) and requested the investigation report. The NHA stated he was unable to find the investigation but would continue looking.
On 10/12/23 at 11:03 AM the surveyor conducted an interview with Resident #42. Resident #42 was not able to provide any information on the alleged abuse from over a year prior.
On 11/16/23 at 1:47 PM, the surveyor conducted a follow-up interview with the NHA where he confirmed no investigation report was found for Resident #42.
8. On 10/19/23 at 11:33 AM, the surveyor reviewed an investigation report from an incident that occurred on 5/14/23 between Resident #115 and #63. The report stated that the two residents were found in an altercation out on the smoking patio. No injuries were reported or found on assessment, and the police were called. In the investigation the facility was unable to determine how the Residents got out onto the smoking patio that allowed them to be unsupervised.
On 10/19/23 at 11:35 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During this interview he stated that there would have been an assigned person to monitor the smoking area but only during assigned smoking times. He further stated there was no staff supervising at the time of the incident and was not sure if this took place during a scheduled smoking time or the residents got the code to the smoking patio and let themselves out. The NHA agreed that the facility failed to interview the staff that was scheduled to supervise smoking that day to better understand how the residents were allowed to smoke unsupervised.
9. On 10/13/2023 at 8:30 AM, a record review revealed that a Facility Reported Incident (FRI) regarding Resident #369 was received by the Office of Healthcare Quality (OHCQ) on 6/6/2022 at 1:47 PM. In the FRI, the facility reported that per Resident #369, on 5/23/2022 a Geriatric Nursing Assistant hit his/her hand.
On 10/13/2023 at 9:30 AM the facility's investigation was requested by the Surveyor.
On 10/16/2023 at 11:00 AM, when asked about the investigation, the Nursing Home Administrator (NHA) stated that he is still trying to locate the file.
On 10/17/2023 at 11:50 AM, the NHA admitted he cannot find the file.
10. On 10/20/2023 at 8:30 AM, a record review revealed that a FRI regarding Resident #70 was received by the OHCQ on 7/14/2022 at 1:57 PM. In the FRI, the facility reported that on 7/13/2022 Resident #70 went out the front door.
On 10/20/2023 at 10:35 AM, the facility's investigation was requested by the Surveyor.
On 10/23/2023 at 10:30 AM, when asked about the investigation, the NHA admitted it is one of several investigations he can't find.
11. On 10/24/2023 at 1:45 PM, a record review revealed that a FRI regarding Resident #128 was received by the OHCQ on 9/08/2022 at 10:50 AM. In the FRI, the facility reported that Resident #128 reported $40.00 went missing.
On 10/25/2023 at 8:00 AM, the facility's investigation was requested by the Surveyor.
On 10/26/2023 at 11:45 AM, Staff #39, a Regional Nurse, stated that the investigation could not be found.
Based on clinical record review, review of facility investigations, and staff interview it was determined that the facility staff failed to ensure allegations of abuse are thoroughly investigated and accurately reported with inclusion of details such as but not limited to reported injury and witness statements. This was evident for 12 (#119, #161, #165, #365, #374, #22, #42, #115, #63, #369, #70, and #128) out of 30 residents reviewed for abuse.
The findings include:
1. A review of Resident #119's clinical record on 10/12/23 revealed that the resident had an incident on 5/3/22 at 11:30 AM. A review of the facility's investigation revealed that the facility reported the incident to the state survey agency but failed to include that the resident suffered an injury.
This surveyor interviewed the Administrator on 10/18/23 at 10:20 AM. He was informed that the incident was reported but the facility failed to mention that the resident suffered an alleged injury as a result of the incident. Explained to the Administrator that an alleged injury is an important detail to include in all injury and abuse reports.
2. A review of two Facility Reported Incidents (FRI's) -- MD00181020 and MD00181170 were started on 11/6/23. The FRI's involved Resident #161's allegations of physical and sexual abuse, respectively. The review of the two investigations revealed that neither had witness statements.
This surveyor interviewed the Administrator on 11/16/23 at 1:12 PM. The Administrator was informed of the importance of having witness statements from the alleged victim, any alleged perpetrator(s), and witnesses or potential witnesses. The Administrator expressed his understanding of the importance of obtaining witness statements.
3. This surveyor started a review of intake MD00175238 on 10/17/23 at 11:30 AM. A review of Resident #165's clinical record revealed Resident #165 was in their bedroom on 4/8/22 when the roommate's daughter went to the nursing station to accuse the resident of stealing her relative's tv remote which has been missing for 4 weeks. The daughter then went into the room and yelled at Resident #165. Resident #165 started to cry and turned on the cell phone to record the incident. The resident's spouse was called, and the spouse called the police.
Resident #165's spouse came to the facility on 4/9/22 at 10:30 AM to request a room change. The facility had already begun the process of moving the roommate. The spouse also reported that a Roku box had been taken as well. The spouse reported the alleged theft to the police.
The roommate's daughter was also an employee (receptionist), so she was suspended and then terminated. The daughter could still visit her relative. No evidence that she was escorted to the unit when she visited and/or prevented from entering Resident #165's room was found.
The Administrator was interviewed on 10/25/23 at 1:40 PM. This surveyor explained the findings to him. He said he understood the daughter took the remote from out of Resident #165's hand and shared with me that he did not believe the daughter went onto the floor after the incident. He then showed me a laptop with a record of all the employees who signed in and out of the facility during the weeks after the incident. He shared that staff are not required to sign in if the facility is not on COVID outbreak status. He stated that he is looking at changing the system so that all staff are required to check in regardless of COVID status.
The Administrator stated on 10/25/23 at 2:09 PM that he talked with the other receptionists, but they did not remember if the alleged perpetrator ever went to floor as visitor. He could not provide evidence that the resident was protected throughout the investigation.
.
4. This surveyor started a review of intake MD00182919, which involved an allegation of abuse of Resident #365, on 11/1/23. The facility investigation was requested on 11/2/23. This surveyor interviewed the Administrator on 11/7/23 at 11:17 AM. He was asked if he had a copy of the investigation. He said he looked on Thursday, Friday, and over the weekend. He said he could not find it. He verified the date of the alleged incident with me and said he would look at the computer scans one more time.
The Administrator was interviewed on 11/8/23 at 12:39 PM. He confirmed that he had no evidence of an investigation. He called the previous administrator, Staff #52, who said she remembers the incident and stated that the alleged perpetrator was suspended.
The Administrator provided proof of the suspension but not the actual investigation.
5. This surveyor started a review of intake MD179333 on 10/30/23.
A review of the facility investigation and Resident #374's clinical record revealed the resident alleged that the nurse supervisor (Staff #70) allegedly pointed her finger at the resident and then hit the resident's nose and face x2. The resident then allegedly fell as a result.
The facility called the police and the state survey agency on 6/21/22. Further review revealed that there were four witnesses, but they were not interviewed. Staff #70 was suspended for 5 days.
The Administrator was interviewed on 10/31/23 at 10:20 AM. He said the incident was initially reported but the final report was not sent to the state survey agency.
The Administrator returned on 10/31/23 at 12:32 PM. He confirmed that the facility has no record of an interview with the resident, the alleged perpetrator, or the witnesses. He said he could not provide proof that the alleged perpetrator was suspended.
The nursing coordinator for the 3rd floor nursing unit (Staff #3) was interviewed on 11/1/23 at 1:15 PM. He said he was coming off of the elevator and saw what happened. The resident had the right hand on a cane and a pill crusher in the left hand. Resident was trying to hit the nurse. When the resident swung down with the pill crusher it hit the nurse's hand and this caused the resident to fall. He said the nurse never hit the resident.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, it was determined that the facility failed to ensu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, it was determined that the facility failed to ensure a care plan was developed for a resident who was an active smoker upon the completion of resident's comprehensive assessment at admission and failed to review, to revise a resident's care plan after a quarterly assessment, to ensure that care plan meetings took place in a timely manner, to ensure a Power of Attorney (POA) was invited to a care plan meeting. This was evident for 6 (Resident #109, #10, #371, #33, #39, and #67) of 12 residents reviewed for care plan timing and revision.
The findings include:
A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. This helps to evaluate the effectiveness of the resident's care.
The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs.
1a. On 9/27/2023 at 8:55 AM, surveyors observed Resident #109 in his/her room. Resident #109 stated I'm going out to smoke.
On 9/27/2023 at 9:39 AM, Activity Assistant, Staff #11, provided the surveyors with a copy of a document titled Resident Smoking revised 2/22/2021, a section under, Policy Explanation and Compliance Guidelines which stated in section:
6). All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment
7). Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all.
10). All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan.
On 9/27/2023 at 12:50 PM, review of resident #109's electronic medical record established that Resident #109 had diagnoses, including but no limited to chronic respiratory failure, COPD (chronic obstructive pulmonary disease: inflammatory lung disease that causes obstructed airflow from the lungs), fracture of vertebrae, traumatic brain injury, high blood pressure, malignant neoplasm of lung, falls, tobacco use, and substance abuse.
On 10/4/2023 at 7:00 AM, Licensed Practical Nurse (LPN), Staff #6, informed surveyors that the resident was discharged [DATE].
On 10/16/2023 at 9:30 AM, during review of Resident #109's electronic medical record, surveyors discovered a MDS focus note dated 8/25/2023 at 11:33 AM, written by Resource MDS Coordinator, Staff #28, revealed that the resident was a current smoker.
On 10/16/2023 at 9:45AM, review of resident's MDS (Minimum Data Set) dated 8/29/2023, revealed that Resident # 109 was cognitively intact, needed limited assistance with mobility, occasionally used a walker or cane at times for mobility, had pain, shortness of breath with exertion and when lying flat, and used tobacco.
Continued review of electronic medical record showed that on 8/22/2023 at 1:15PM Resident #109's smoking assessment was completed. It revealed that the resident was an unsafe smoker with some weakness noted and supervision was required during smoking. The assessment also stated that Resident #109 appeared to have physical limitations which interfered with the ability to perform safe smoking techniques.
On 10/17/2023 at 12:30 PM, review of Resident #109 care plans from 8/22/2023 through 10/3/2023, concluded that there was no care plan for smoking initiated.
On 10/18/2023 at 7:45 AM, surveyors conducted an interview with Unit Coordinator, Staff #21. During the interview, Staff #21 stated that a smoking assessment is completed by the nurse on admission to determine the smoking parameters for a resident who smokes. Staff #21 also stated that there should be a care plan created for a smoking resident. If the smoking assessment reveals that the resident is an unsafe smoker, they may go to the smoking area with an aid for assistance and that should be included in the care plan.
On 10/27/2023 at 11:30 AM, the surveyor expressed the concerns with Regional Director of Clinical Operation (RDCD), Staff #39 and the Administrator.
1b. On 10/19/2023 at 7:13 AM, Surveyors noted a diagnosis of pneumonia as an active condition on the Quarterly MDS assessment dated [DATE] for Resident #109.
On 10/19/2023 at 10:10AM, review of Resident #109's electronic medical record, surveyors note a chest x-ray to be completed 9/1/2023 at 3:18 PM to rule out pneumonia ordered by Physician, Staff #50.
During further review of records, surveyors discovered a note created by Staff #50, on 9/5/2023 at 11:30 PM establishing the chest x-ray confirmed pneumonia and that Resident #109 will start on antibiotics as treatment for 7-10 days.
On 10/19/2023 at 10:50AM, surveyors note that the MDS assessment history reflected that a quarterly MDS assessment including pneumonia was completed on 9/14/2023. Surveyors discovered that there was no documentation to indicate that Resident #109's care plan was revised based on the diagnosis included in the quarterly MDS assessment.
The identified concerns were reviewed with the interim Director of Nursing (DON), the Administrator, and the Regional Director of Clinical Operations (RDCO) throughout the survey process and at the exit conference on 11/20/2023. There was no documentation provided to surveyors regarding initiation and implementation an updated care plan for Resident #109.
6. A medical Power of Attorney (POA) is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent or a durable power of attorney for health care.
A Care Plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
During the review of a complaint by the surveyor on 10/19/2023 at 1:25 PM, the complainant reported that s/he was the POA for Resident #371 and was unable to participate in his/her care because the facility failed to discuss the resident's care plan and failed to return phone calls regarding the resident's care. Review of the medical records did not reveal documentation of care plan meetings or notifications to the POA for the care plan dated 10/9/21.
On 10/20/23 at 9:00 AM, during an interview with the Regional Director of Clinical Operations (RDCO), the surveyor shared the concern that the POA had not been notified of the care plan meeting for Resident #371 and requested a copy of notification and the care plan meeting notes.
During an interview on 10/20/2023 at 12:58 PM, the RDCO stated the facility is not able to provide POA notification of a care plan meeting for the care plan dated 10/9/21 or notes from the meeting and the facility would start tracking care plan meetings and notifications.
2. On 09/27/2023 at 10:20 AM, Resident #10 reported that he/she was not told when the last care plan meeting was scheduled and had been trying to schedule a care plan meeting.
A subsequent record review revealed that the last care plan meeting was held on 03/14/2023.
On 10/05/2023 at 10:39 AM, an interview with Staff #14, a social worker, revealed that care plan meetings are supposed to be scheduled 7 days after admission, quarterly, and if there is a significant change.
On 10/12/2023 at 11:45 AM, Resident #10 reported that he/she was still trying to have a care plan meeting scheduled. At 1:15 PM this was brought to the attention of Staff #14 from the social work department.
3. A review of Resident #33's clinical record on 9/27/23 revealed care plan meetings have not been held for the resident for the past year.
The Social Work Director (Staff #14) was interviewed on 10/3/23 at 1:46 PM. Staff #14 said she is responsible for planning the care plan meetings. She keeps sign-in sheets from the meetings in her office. She looked for sign-in sheets for the resident but could not find any. She confirmed that the resident's brother has requested to be invited to care plan meetings on numerous occasions.
4. Resident #39 was interviewed on 09/27/23 at 08:17 AM. Resident stated that he/she doesn't go to the meetings because they used to invite the residents but not anymore. A review of Resident #39's clinical record on 9/27/23 revealed that there was no evidence that the resident has been invited and/or attended any care plan meeting.
The Social Work Director (#14) was interviewed on 10/3/23 on 1:46 PM. Staff #14 said she is responsible for planning the care plan meetings. She keeps sign-in sheets from the meetings in her office. She looked for sign-in sheets for the resident but could not find any.
5. Resident #67 was interviewed on 9/28/23 at 8:10 AM. The resident stated that they did not know what a care plan meeting was. A review of the resident's clinical record revealed that there was no evidence that the resident had been invited to a care plan meeting since admission.
The Social Work Director (#14) was interviewed on 10/3/23 on 1:46 PM. Staff #14 said she is responsible for planning the care plan meetings. She keeps sign-in sheets from the meetings in her office. She looked for sign-in sheets for the resident but could not find any.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure that 1) pres...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure that 1) prescribed medications are correctly transcribed and administered, 2) insulin sliding scale parameters were included on the medication order for a resident receiving insulin, 3) report changes in baseline conditions and health concerns verbalized by residents. and 4) to create a new medication order in the resident's electronic record, once the order had been changed, and facility staff administered narcotics with conflicting orders.
This was evident for 1) 2 (Resident # 39 and #46) of 6 residents investigated during the medication administration and investigative portion of the survey, 2) 1 (Resident #39) of 6 observed during the medication administration task portion of the survey, 3) 3 out of 3 monthly Dialysis Communication Logs reviewed during the survey, and 4) 1 Resident (#93) identified in 2 out of 3 narcotic binders reviewed during medication storage observations.
The findings include:
Polyneuropathy is a condition in which a person'ss peripheral nerves are damaged. It affects the nerves in your skin, muscles, and organs. When these nerves are damaged, they can't send regular signals back to your brain.
Insulin is an essential hormone that helps your body turn food into energy and controls your blood sugar levels to keep them in the normal range of 70 mg/dl and 100 mg/dl.
A sliding scale varies the dose of insulin based on the blood glucose level. The higher your blood glucose the more insulin you receive.
Dialysis is a process that helps with the removal of waste products from the blood normally done by the kidney.
A Communication Log is a place to document important details of a resident's care and the action taken.
1. On 10/11/2023 at 8:33 AM, during the medication administration task, surveyors observed Licensed Practical Nurse, Staff #23, obtain Resident #39's blood sugar level. Surveyors noted that the resident was sitting up in bed with the tray table across the legs. The resident reported he/she had already eaten breakfast consisting of a biscuit, gravy, and orange juice. Staff #23 retrieved Resident #39's insulin pen from the medication cart.
Staff #23 and surveyors reviewed Resident #39's medication administration record which revealed an order for 3 units of insulin to be given subcutaneously (insertion of medication beneath the skin by injection) three times daily with meals for Diabetes Mellitus. Surveyors discovered that there was no sliding scale.
Diabetes Mellitus is a disease that affects how the body uses sugar- too much sugar in the blood.
On 10/11/2023 at 8:40 AM the surveyors interviewed with Staff #23. Staff #23 stated that, residents receiving insulin are usually on a sliding scale. Staff #23 informed surveyors that she would call the doctor to inquire about why there was no sliding scale order.
On 10/11/2023 at 12:35 PM, surveyor interviewed with Physician, Staff #50. During the interview, Staff #50 stated that, residents on insulin are usually on a sliding scale. The surveyor informed Staff #50 that the surveyors and the assigned nurse, Staff #23, could not locate the sliding scale insulin for Resident #39. Staff #50 stated she would look into it and get back with surveyors.
A follow-up interview with Staff #50 was conducted 10/13/2023 at 11:06 AM. Staff #50 states, All residents receiving insulin should be on a sliding scale. Resident #39 should have a sliding scale. The pharmacy recommends that we keep the residents receiving insulin on a sliding scale for 2 weeks. I like to keep them on a sliding scale at a low dose because they (residents) like to eat snacks and the snacks increase their (residents ' ) blood sugars. I ordered the sliding scale for Resident #39.
On 10/13/2023 at 12:10 PM, review of Resident #39's medical records showed an order for insulin with a sliding scale created on 10/12/2013 at 11:30 AM.
The identified concerns were reviewed with the Director of Nursing and Administrator throughout the survey and again at 12:30 PM on 11/17/2023.
3) During initial tour of the unit on 9/27/2023 at 9:05AM, surveyors observed Resident #517 sitting up in bed, sweating heavily with hair and shirt wet, head bent while rubbing the back of neck, and restless in bed. Surveyors also noticed a CVC (central venous catheter: an access used for administering medications) in his/her left chest and AVF (arteriovenous fistula: dialysis port) in his/her right upper arm.
Surveyors conducted an interview with Resident #517 on 9/27/2023 at 9:09 AM. The surveyors asked how he/she was feeling and he/she responded by saying I'm so hot. The resident said he/she was in pain. Surveyors asked where the pain was located, and the resident stated the pain was in the back of his/her neck where he/she recently had surgery. Surveyors asked the resident how he/she would rate the pain from 0-10 pain scale (0 being no pain and 10 being the worst pain). The resident was unable to verbalize the severity of pain but surveyors observed the resident was sweaty and grimacing.
On 9/27/2023 at 9:14 AM, surveyors notified the Unit Manager, Staff #1, of resident's condition. Surveyors observed Staff #1 knock on Resident #517's door and then enter the resident's room. Staff #1 placed the resident's breakfast tray on the bedside table and raised the head of the bed.
On 9/27/2023 at 9:50 AM, review of Resident #517 electronic medical records revealed that the resident was admitted on [DATE] with diagnoses that included, but no limited to, end stage renal disease (kidney disease), dependence on renal dialysis, osteomyelitis (bone infection), hypoglycemia, laminectomy due to fusion of spine, and chronic postprocedural pain. The admission assessment dated [DATE] showed that the resident was cognitively intact, alert, and able to make his/her own decisions.
On 9/28/2023 at 8:33 AM, during record review, it was noted that Resident #517 was transferred from the Dialysis Clinic within the facility to the hospital 9/27/2023 at 11:05 PM. A nursing progress note, written by Staff #1 on 9/27/2023 at 10:35 AM, stated that Resident #517 was transferred to the hospital emergency room due to hypoglycemia (low blood sugar).
On 9/28/2023 at 8:40AM, surveyors toured the unit and observed random dialysis communication binders, located on a desk at the nurses' station. A communication binder for Resident # 517 was not located during the tour. Staff #1 was at the nurses' station when surveyors asked Staff #1 where Resident #517's Dialysis Communication form was located and Staff #1 replied, I will look for it. The form was never located while surveyors were on the unit with Staff #1.
On 9/28/2023 at 2:29 PM, during an interview with Staff #1 and the interim DON, Staff #1 revealed that the resident was sweating a lot, she got him/her some juice, and he/she drank a little. Staff #1 informed surveyors that she sent the Dialysis Communication form with Resident #517 when he/she went to dialysis on 9/27/2023. Staff #1 presented the surveyors with a copy of Resident #517 ' s Dialysis Communication Form. Surveyors, Staff #1, and the interim DON reviewed the form and discovered the form was incomplete. The form did not include the resident ' s current health status (at the time of transfer from the unit to the Dialysis clinic). The interim DON and Staff #1 confirmed that the form did not include the important information needed to transfer Resident #517 to the dialysis unit.
On 9/29/2023 at 7:00AM, Surveyors conducted an interview with the Dialysis Post-Acute Services Nurse, Staff #74. During the interview, Staff #74 revealed that GNA (Geriatric Nursing Assistant), Staff #13, brought the resident to the dialysis clinic unexpectedly on 9/27/2023 at 10:00AM. Staff #74 went on to say that Resident #517 was drooling, non-verbal, shaking, diaphoretic (sweating heavily), soaking wet, unstable, and did not look well. Resident #517 could not communicate with me and the resident never received dialysis that day. He/she did not come to the dialysis clinic with his/her dialysis communication form. Surveyors showed Staff #74 a copy of the form that Staff #1 provided to surveyors on 9/28/2023. Staff #74 confirmed that the dialysis communication form did not come with the resident that day. Staff #74 let surveyors know that the dialysis staff do not have access to the facility ' s electronic medical record for residents, so the dialysis communication form is how nursing staff and dialysis staff would communicate resident care before and after dialysis.
On 9/29/2023 at 10:27AM, surveyors reviewed the facility ' s Dialysis policy. The policy states that nursing staff will provide a report to the dialysis provider regarding the resident ' s condition and treatment provisions each dialysis treatment day, and as needed.
On 9/29/2023 at 10:53 AM, Surveyors interviewed Staff #13 who revealed, she usually informs the nurse when she ' s taking the resident to dialysis. Resident # 517 didn't have a dialysis binder available.
On 10/3/2023 at 9:30 AM, surveyors interview the Unit Coordinator, Staff #21 who stated that the Dialysis Communication Form should be filled out entirely especially the areas pertinent to the residents condition before being transported to the dialysis center. If there is a change in condition observed, it is to be included on the form to inform the dialysis staff. The sending nurse should sign off on the form and send the form to the Dialysis Clinic with the resident.
The identified concerns were communicated to the interim DON and Administrator throughout the investigation and again at 12:30 PM on 11/17/2023.
4. Review of the Narcotic Binder on 10/12/2023 at 9:18 AM, revealed a Medication Monitoring Control Record with pharmacy label for Resident #93 that included an order written on 6/14/2023 by Physician's Assistant, Staff #56, that read: Give [opioid] 5 mg (milligram), 1 tablet by mouth, every four hours, as needed for pain.
During record review in the presence of Staff #25 on 10/18/2023 9:25 AM. the medication monitoring control record for Resident #93 showed that, daily from 10/11/2023 through 10/16/2023, facility staff documented administering 2 tablets of {opioid} 5 mg, to Resident #93 for a total of 15 doses administered.
On 10/18/2023 at 9:30 AM, further investigation into Resident #93's medical record revealed an order in PCC (the electronic medical record) that read: Give {opioid}10 mg (milligram), 1 tablet by mouth, every four hours, as needed for pain.
On 10/18/2023 at 9:50 AM interview was conducted with Staff #25 in the presence of the interim DON. Staff #25 stated the Physician's Assistant, Staff # 56, changed Resident #93's {opioid order} and he {staff #25} wrote on the {opioid} label Direction change, 2 tablets every four hours.
On 10/18/2023 11:30 AM, the interim DON submitted documents to surveyors titled, One on One Education and Controlled Substance Administration and Accountability policy with signatures listed from all Unit Managers and various licensed nurses as having received the education.
An interview was held on 10/26/2023 AM with Staff #56, which revealed the expectation was that the medication would not be wasted because if she had changed the order in the electronic record, the pharmacy would've taken too long to deliver the medication and it didn't make sense to waste it. The nurses are to follow the medication orders in PCC.
A subsequent interview was conducted with the Regional Director of Clinical Operations, (RDCO) on 10/26/2023. The RDCO confirmed that medication orders between the resident's electronic record and the medication monitoring control record were to be the same. The RDCO provided surveyors with a document titled One on One Education with the topic: When orders are placed in PCC, the old orders need to be discontinued. This includes pain medications and other medications. The educator was listed as the Medical Director and the document was signed by Staff #56.
The interim DON, RDCO and Administrator were made aware of the identified concerns throughout the survey and again at survey exit.
5a. A review of the resident's Medication Administration Record (MAR) on 11/2/23 at 08:00 am revealed an admission order dated 06/22/23 for Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth one time a day every Mon, Wed, and Fri for nerve pain; To be given after dialysis.
However further review of the monthly MARs showed that Resident #46 had received Gabapentin 3 out of 7 days per week since their June 2023 admission. Further review of the Gabapentin monthly administration record found 74 missed doses from June 24, 2023, through November 3, 2023.
During an interview with Resident #46's physician (staff # 50) on 11/02/23 at 10:15 AM it was revealed that it was expected that all admission orders are reviewed at least twice, once by nursing and the other by a physician. Staff #50 added that the nursing staff reviews can be completed with the physician over the phone.
According to Resident # 46's Nursing Unit Coordinator (staff#3) during an interview conducted on 11/03/2023 at 1:45 PM, he performed daily reviews and reported any discrepancies he found to the residents' physician and the Director of Nursing. He also indicated that it was his responsibility to oversee physicians' order management and monitoring by daily progress notes and physicians' order reviews that included a review of all new admissions' documentation to ensure orders are written and transcribed accurately and administered to residents accordingly. This was conducted through the reviews of all MARs and Treatment Administration Records and provided notifications to pharmacy for needed corrections associated with them. He also provided staff education as needed. During the interview he confirmed he knew Resident #46. When asked he stated he have been doing the reviews but never found any issues with Resident #46's medication orders.
During the interview staff #3 reviewed Resident #46's admission order for Gabapentin and the transcribed administration instructions on the June 2023 - November 2023 MARs shared by the surveyor. Staff #3 acknowledged that the admission orders for the Gabapentin's, administration, and the monthly MARS transcriptions were inaccurate, should have been reviewed, and verified by the resident's physician before transcribed and checked by nursing for accuracy before administrating the medication to the resident. He also acknowledged the undetected inaccurate orders and MARs for Resident #46 caused continuous medication errors that resulted in the 74 missed doses from June 2023 through November 2023.
During a follow-up interview with staff # 50 on 1/07/23 at 2:00 PM, when asked she stated staff #3 had made her aware of the inaccurate order and dosage frequency transcription errors for Resident #46's Gabapentin medication.
5b. Record reviews that involved intake # MD00196805 was conducted on 11/07/23 at 11:47 AM. Review of the intake revealed Resident #46 expressed concerns of multiple episodes of high blood pressure that had not been addressed by staff. The medical record review revealed that Resident #46 was admitted to the facility with diagnosis that included high blood pressure (aka Hypertension or HTN), and kidney failure requiring dialysis. Further review showed Resident #46 had weekly dialysis treatments in a satellite dialysis center located in the facility scheduled for Mondays, Wednesdays, and Fridays weekly. Review of the Medication Administration Record (MAR) revealed a physician order dated 06/23/23 for a 30 mg tablet of the medication Nifedipine was to be given by mouth four (4) times a week to help control the resident's HTN.
During an interview with the Dialysis Center Nurse (staff #74) on 09/29/23 at 9:43 AM she stated that Resident #46 was scheduled for dialysis treatments every Mondays, Wednesdays, and Fridays. She added since the dialysis staff do not have access to the facility's residents' electronic medical records, Each resident has a Dialysis Communication Form completed for every visit to the dialysis center. On the form, the resident's nurse would complete the top portion titled Pre-Dialysis (PD) information. The middle section titled Dialysis Center Information (DCI) was completed by the dialysis nurse. The bottom section titled Post-Dialysis Information (PDI) was completed by the unit nurse upon return from dialysis. She said that all 3 entries required the licensed nurses to include important information that ensured the resident's physical condition was monitored before, during, and after dialysis and all identified problems were reported to the resident's physician for further investigation. The information included the current blood pressure reading, (BP) heart rate (Pulse), respirations (breaths taken per minute), body temperature and any complaints of pain. Staff # 74 added that the forms were kept in a binder at the nurses stations on the unit.
On November 7, 2023, at 10:30 AM, a review of Resident #46's Dialysis Communication Binder was conducted for the months of July 2023 through October 2023. A review of August 2023 forms revealed that on August 7, 2023, staff # 74 indicated the resident's blood pressure at the dialysis center was recorded at 181/103. The nurse also indicated that the resident complained of a headache at a level 5 out of 10. (0 meaning no pain and 10 meaning the worst pain) Further review of the 8/7/23 report showed that the unit nurse's post - dialysis documentation indicated the resident's BP was 139/84 and reported a headache at a level of 10 out 10. (Blood pressure is measured using two numbers: The first number, called systolic blood pressure, measures the pressure in your arteries when your heart beats. The second number, called diastolic blood pressure, measures the pressure in your arteries when your heart rests between beats. Blood pressure is considered high (stage 1) if it reads 130/80. Stage 2 high blood pressure is 140/90 or higher. A blood pressure reading of 180/110 or higher more than once, is considered an hypertensive crisis.)
Further review of the August Communication Forms revealed 7 out of 7 visits to the dialysis center the resident BP was recorded between 139/84 and 181/103. Further review found that on August 9, 18 and 25, all three BP readings on the communication forms were between 139/84 and 181/103. On August 14, it indicated 2 BP readings between 139/84 and 181/103. Additional review of the August log indicated Resident #46 complained of a headache 5 of the 7 visits and headache with body pain on August 14. However, there was no documentation found to support that the resident's physician was notified of the abnormal blood pressures or the complaint of headaches or body pain.
During a brief interview with Resident #46's primary physician (staff #50) on 11/02/23 at 10:15 AM she stated that on 08/17/23, she visited the resident at their request to discuss their concerns. Resident #46 spoke of multiple occurrences of elevated high blood pressure readings with occasional head and body aches which had recently increased in frequency and intensity. She added that there was a review his current blood pressure but was unable to confirm his concerns, so she ordered for nursing staff to record his blood pressures every shift for a few days to validate the resident's concerns and determine if any adjustments in the resident's blood pressure medication regimen was needed.
A record review for Resident #46 conducted on 11/02/23 at 12:15 PM revealed a progress note written by staff #50 that confirmed the 08/17/23 visit with Resident #46 and his/her expressed concerns regarding their blood pressure. However further record review failed to show any additional blood pressures were recorded that day or instructions parameters given to increase the number of BP readings for the resident were added.
A review of the August 2023 Treatment Administration Records (TAR) failed to show any requests for vital sign monitoring for Resident # 46. Further review of the TAR shows the resident's vital signs were discontinued on 08/17/2023 and no new order for vital signs were found.
During an interview with Resident #46's Nursing Unit Coordinator (staff #3) on 11/03/2023 at 1:45 PM, he stated that although the order for vital signs were discontinued, the nursing staff conducted daily screens of the residents that included blood pressure records. However, a review of the blood pressures recorded on the July 2023 and October 2023 TARs with staff #3 failed to correlate with the BPs recorded on communication forms. Further review found BPs readings on the TARs that warranted physician notification, but no documentation was found or presented to indicate that this was done.
A review of the August 2023 Medication Administration Record for Resident #46 conducted on 11/02/23 at 1:30 PM indicated that on 08/18/2023, the 06/22/23 order for Nifedipine Extended Release (ER) was changed from 30mg one time a day every Tuesday, Thursday, Saturday, and Sunday to Nifedipine ER 30 mg one time daily. Further record review by surveyor found no documentation to support that an order was placed to monitor the frequency of elevated blood pressures, or guidance to determine reportable abnormal blood pressure readings to the physician nor any additional blood pressure readings were conducted.
A review of Resident 46's September 2023 Dialysis Communication Forms indicated that 6 of 6 dialysis treatment visits the resident's BPs was recorded between 143/81 and 194/88. On 9/29/23 all three recorded BPs were 155/86 and 164/88. On 09/01/23 the Dialysis Center BP was recorded as 152/90 and the Post Dialysis BP was recorded as 148/96. Further review found 4 of 6 visits failed to indicate a pre or post dialysis BP readings were recorded. On 9/20/23 no pre or post dialysis BP readings were indicated on the form.
Review of October's Dialysis Communication Forms indicated that 7 of the 7 dialysis treatment visits Resident #46' blood pressure was recorded between 150/90 and 166/101. On October 18, and 20, 2023, all 3 recorded BPs were between 152/84 and 160/94 and on 10/27/23 the dialysis center's BP was recorded as 166/101, with a complaint of a headache at a level of 6 out of 10 and the resident's post dialysis BP was recorded as 156/82 for the resident.
Further record review failed to show that staff #50 was notified of the BP readings recorded after she adjusted Resident #46's Nifedipine administration frequency on 8/18/23.
During the 11/03/2023 at 1:45 PM interview with staff #3, he stated he conducted daily reviews of progress notes, followed-up on new admissions, and physician order changes to ensure orders are written and transcribed accurately and administered to residents accordingly. Noted discrepancies were referred to the physician and Director of Nursing (DON). He conducted any needed documentation follow ups, pharmacy notifications, and provided nurse education. The reviewed information is discussed in daily meetings in-person or by phone call with nurses on the unit, the DON, the Administrator, and others as determined.
When asked by surveyors, who was responsible for the review of the facility's Dialysis Communication Forms, he shared that his responsibilities included a daily review of the facility's Dialysis Communication logs and the recurrent Medication and Treatment Administration Records monthly and periodic changes that occurred in between.
When Staff #3 was asked what would you consider to be an example of an elevated blood pressure reading, he responded in general BP baseline for all residents: are between 130 - 140 and post dialysis 120. Low BPs are common with dialysis residents. Surveyors asked what he expected the nurses response to be if a resident's BP is over or under the baseline blood pressure. Staff #3 replied that the nurse would attend to the patient. Check if resident was medicated if not administer and recheck the BP. If not medicated notify the MD (Medical Doctor) and document the incident in the electronic health record.
He added it is also his responsibility to read the pre and post dialysis notes and communication forms, for any change in condition, and follow-up on documentation related to reports, and any reporting and communications from dialysis.
During the interview he confirmed he knew Resident #46. When asked he stated he have been doing the reviews but never found any issues with Resident #47's communication log reviews.
The surveyor showed the progress note documented on 8/17/23 that involved the conversation between staff #50 and the resident who stated had expressed multiple concerns to staff regarding elevated BP levels and the surveyor's concerns noted during the record reviews. Staff #3 responded that the COVID-19 assessments included the BP checks and would have been documented there.
On 11/03/23 at 2:15 PM, a review of the COVID-19 assessment screenings for Resident #46 was conducted. Review of August through October 2023 assessments revealed sixteen (25) incidents an automated exceeded 139 systolic thresholds alert was triggered related to the resident's recorded BP readings submitted by nursing staff. Further review found no evidence that the alerts were reported to Resident #46' physician or associated documentation to support that the BPs were addressed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. On 9/27/2023 at 9:09 AM, during a tour of the unit, surveyors observed Resident #517 sitting up in bed, sweating heavily with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. On 9/27/2023 at 9:09 AM, during a tour of the unit, surveyors observed Resident #517 sitting up in bed, sweating heavily with hair and shirt drenched, head bent while rubbing the back of neck, and restless in bed. Surveyors noticed a CVC (central venous catheter: an indwelling tube into the vein used for medications) in his/her left chest and AVF (arteriovenous fistula: dialysis port) in his/her right upper arm. During an interview with Resident #517, surveyors asked how he/she was feeling. Resident #517 responded by saying I ' m so hot. The resident ' s speech was slurred and hard to understand during the conversation. At 9:14 AM, Surveyors expressed concerns to Unit manager #1 regarding Resident #517 ' s condition.
On 9/27/2023 at 9:50 AM, review of Resident #517's electronic medical records confirmed that the resident was admitted on [DATE] with diagnoses that included, but was not limited to, end stage renal disease (kidney disease), dependence on renal dialysis, osteomyelitis (bone infection), laminectomy, fusion of spine, heart failure, high blood pressure, hypoglycemia, severe protein calorie malnutrition, chronic hepatitis C, and chronic postprocedural pain. The admission assessment dated [DATE] showed that the resident was cognitively intact, alert, and able to make his/her own decisions.
On 9/28/2023 at 8:33 AM, during record review, surveyors discovered a nursing progress note written by Staff #1 on 9/27/2023 at 10:35 AM stating that Resident #517 was being transferred to the hospital emergency room due to hypoglycemia (low blood sugar), shortly after being taken to the dialysis clinic within the facility. Staff #1 noted the resident to be diaphoretic (sweating heavily), shaking, and unable to speak clearly, with a low blood sugar reading.
On 9/28/2023 at 1:49 PM surveyors conducted an interview with the Interim Director of Nursing (DON). Surveyors expressed the concern that Resident #517 was visibly unstable before being sent to the dialysis clinic and then transferred to the hospital as a result.
An interview with Staff #1 on 9/28/2023 at 2:29PM, revealed that she was aware that the resident was unstable during her encounter with Resident #517 on 9/27/2023 at 9:14AM. Staff #1 stated that she was aware the resident was hypoglycemic, but did not check the resident's blood sugar before sending him/her to dialysis. She stated that she was made aware of Resident #517's condition from the dialysis clinic and asked to retrieve the glucagon emergency kit for the resident. from the medication cart and told to Licensed Practical Nurse (LPN) # 104 to administer it to the resident. Staff #1 did not go to the dialysis clinic to assess the resident while he/she was there.
The Interim DON was present during the interview with Staff #1. The interim DON informed the surveyors that in an emergency, nurses can give glucagon and then request an order from the physician later.
On 9/29/2023 at 7:00AM, Surveyors conducted an interview with Dialysis Post-Acute Services Nurse, Staff #74. During the interview, Staff #74 revealed that Geriatric Nursing Assistant (GNA), Staff #13, brought Resident #517 to the dialysis clinic unexpectedly on 9/27/2023 at 10:00AM. Staff #74 stated that the resident was on the schedule for 9/27/2023 at 1:00PM.Staff #74 stated that Resident #517 was drooling, non-verbal, shaking, diaphoretic (sweating heavily), soaking wet, unstable, and did not look well, and could not communicate with her. Staff #74 asked Staff #13 does the nurse know he/she looks like this? Staff #13 stated Yes. Staff #74 informed us that she was able to get the resident to the hemodialysis chair with assistance, obtain vital signs and a blood sugar level. The blood sugar level was so low that it would not register on the glucometer. Staff #74 gave the resident glucose gel to help increase blood sugar. The blood sugar check 15 minutes after administration of the gel and the level still didn't register. Staff #74 called the nursing unit to ask Staff #1 for an emergency glucose kit. Licensed Practical Nurse (LPN), Staff # 104 arrived at the dialysis clinic with the glucose syringe and administered the medication to the resident. Physician # 103 arrived at the dialysis clinic about 10:45AM and assessed the resident. Resident #517's blood sugar was checked after 10 min and registered at 68. Staff #74 rechecked Resident #517 blood sugar 2 more times and both readings were low. 911 was called and the resident was transferred to the hospital. The resident never received hemodialysis that day. Staff #74 stated she notified Staff #1, Administrator, and Interim DON of Resident #517's condition while at the dialysis clinic 9/27/2023 at 10:00AM.
On 9/29/2023 at 7:45 AM, during review of Resident #517's electronic medical record, surveyors discovered a daily nursing charting assessment dated [DATE] at 1:53PM. The assessment revealed that Staff #1 inaccurately assessed changes in level of consciousness, orientation, cognition, or communication status.
On 9/29/2023 at 10:34 AM, Surveyors interviewed Resident #517 in his/her room. Resident #517 stated that he felt queasy, threw up, and broke out into a sweat on 9/27/2023. The resident stated he/she told the nurse. Resident #517 was unable to recall leaving his/her room and going to the dialysis clinic.
On 9/29/2023 at 10:53 AM, surveyors interviewed Staff #13. Staff #13 stated that she was instructed to take the resident to dialysis by Staff #1. Staff #13 said that the resident was very sweaty and unsteady during transfer to wheelchair. Staff # 13 told Staff #1 of Residents #517's condition before she left the unit. Staff #13 stated that she usually takes the residents to dialysis with a dialysis communication form, but Resident #517 did not have one.
The identified concerns were reviewed with the Administrator and Interim DON throughout the investigation and on 11/20/2023 at 12:30 PM.
4. During a review of the June 2021 Medication Administration Record (MAR) on 10/17/23 at 8:10 AM, the surveyor identified that Resident #381 had missed 107 out of 870 medication doses documented as administered on the MAR. This was indicated with a blank space for the date and time the medication was to be administered.
On 10/17/23 at 1:26 PM, the surveyor interviewed the Regional Director of Clinical Operations (RDCO) regarding the concern of Resident # 381's missing medication doses from June 2021. She stated that she would investigate and get back to the surveyor.
During an interview on 10/18/23 at 7:44 AM the RDCO stated that she reviewed the progress notes, but she was not able to find documentation of refusal in Resident # 381's progress notes from the missing doses in June 2021 and that staff would be trained on the proper documentation of medication administration.
5. On 11/8/23 at 3:30 PM, the surveyor reviewed Resident #63's medical record. The review revealed a change in condition note written on 11/7/23 by Registered Nurse Staff #31. The note described the nurse gave Resident #63 his/her Methadone (a medication given to help Substance Use Disorder) at around 10:30 AM. It further described that the medication appeared to be due to be given in the Electronic Medication Administration Recorded (eMAR). After the administration of Methadone, the nurse then realized that the previous shift signed out the medication in the logbook, stored where the medication was located but not in the MAR.
On 11/9/23 at 2:07 PM, the surveyor interviewed Staff #31. In the interview Staff #31 stated she was orientating a new nurse, and the new nurse informed me that she had given the Methadone that was due for Resident #63. Staff #31 stated, when she reviewed the medication change of custody record for Resident #63's Methadone she discovered that Resident #63's Methadone had already been documented as taken from the supply on 11/7/23. Staff #31 stated the new nurse failed to sign out the medication on the medication chain-of custody record when she took the Methadone. Staff #31 stated they asked Resident #63 if the previous nurse had given the medication but Resident #63 could not recall if he/she had received a dose earlier in the day. She further stated, the physician was notified, and the Resident was monitored with no issues. Staff #31 reported she provided education to the new nurse that at the time Methadone is removed to be given, staff needs to endorse that the medication was taken on the chain of custody form and when removing the medication, to verify the time the last dose was removed on the chain of custody form.
On 11/17/2023 9:49 AM, the surveyor interviewed the 3rd floor Unit Manger Staff #3. During this interview Staff #3 confirmed that when Methadone is taken for administration the staff is expected to sign the medication chain of custody record as well as document the medication was administered in the eMAR. At this time the surveyor reviewed Resident #63's medication chain of custody record. The record indicated on 11/7/23 two doses were signed out on a medication that was to be given daily.
The surveyor interviewed the Nursing Home Administrator (NHA) on 11/16/23 at 1:47 PM. During the interview, the surveyor informed the NHA of the concern related of Staff not following medications administration practices.
An indwelling urinary catheter (Foley) is a tube that drains urine from the bladder into a bag outside the body. It is held in place in the bladder by a balloon.
6. On 09/29/2023 at 9:53 AM, Resident #16 was observed to have a Foley catheter. Per resident, in April, he/she had a urinary tract infection. He/she stated, it went to my blood.
On 10/02/2023 at 8:08 AM, a medical record review revealed that Resident #16 had gone out to the hospital in March. From the time the resident returned from the hospital on 3/23/23 to the time the resident went back out to the hospital on [DATE], there were no active orders for Foley catheter care/maintenance.
Foley catheter care/maintenance orders would have been necessary to guide the nursing care. It is the standard of practice to have orders in place instructing nursing to maintain the Foley catheter. Maintaining the catheter includes, but is not limited to, checking placement and for drainage. Additionally, there were no progress notes during this time that indicated Foley catheter care was being performed.
A review of hospital notes dated 04/17/2023, revealed that Resident #16's condition was due to septic shock and a urinary tract infection. Regarding the Foley catheter, he/she was found to have incomplete drainage given inappropriate foley catheter plaent.
On 10/03/2023 at 10:16 AM, the Director of Nursing (DON) acknowledged there should have been orders for catheter care/maintenance. Per the DON, ultimately it would have been the nurses' responsibility to ensure those orders were in.
The findings include:
8. A review of Resident #162's closed medical record on 10/26/23 revealed that Resident #162 had been admitted to the facility on [DATE] with diagnoses that included: metabolic encephalopathy, liver abscess, diabetes, substance abuse disorder, and sepsis. Resident #162 was discharged on 10/17/23.
A review of Resident #162's physician admission orders, dated 09/28/23 at 10:05 PM, revealed the following medication orders:
1) Ceftriaxone, 2 Grams, IV, every day for 4 days. Did not receive a dose until 10/01/23.
2) Fluticasone Nasal Spray, 2 sprays each nostril, every day, for Allergies. Did not receive a dose until 10/01/23.
3) Lasix, 20 mg, orally, every day, for edema. Did not receive a dose until 09/30/23.
4) Insulin Detemir, 7 units, subcutaneously, at bedtime. Did not receive a dose until 10/01/23.
5) Levocetirizine, 5 mg, orally, every day, for antihistamine. Did not receive until 10/01/23.
6) Methadone, 35 ml (70 mg), orally, every day, for drug therapy. Did not receive a dose until 09/30/23.
7) Montelukast Sodium, 10 mg, orally, every day, for COPD/asthma. Did not receive a dose until 09/30/23.
8) Cipro, 500 mg, orally, twice a day for 21 days, for liver abscess. Did not receive a dose until 10/01/23.
9) Albuterol Inhaler, 2 puffs, 4 times a day, for shortness of breath/wheezing. Did not receive a dose until 10/01/23.
10) On 10/12/23 at 5:19 PM, Permethrin 5 % cream, apply to full body, every day for 14 days. For insect bites. Never received an application.
11) The staff also failed to order the medication Narcan as needed. The resident has a history of substance abuse disorder and was receiving the medications Methadone for addiction and Oxycodone for pain.
In a telephone interview with the facility pharmacy manager on 10/27/23 at 10:37 AM, the facility pharmacy manager stated that the pharmacy did receive Resident #162's admission medication requests on 09/28/23. On 09/29/23 all of Resident #162's medications were placed in a profile only status as the facility nursing staff, when ordering, did not request the medications to be sent. The pharmacy staff placed Resident #162's medications into the system so the nurses can see the MAR in the resident's record. On 09/30/23, medications were still in a profile only status until one of the facility nurses called and requested the pharmacy to send the medications.
9. A review of Resident #131's closed medical record on 10/27/23 revealed that Resident #131 had been admitted to the facility on [DATE] with diagnoses that included: end stage renal disease on hemodialysis, opioid abuse, anemia, GERD, atrial fibrillation, and blindness.
Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure.
A review of Resident #131's physician orders, dated 02/12/22, revealed orders to administer the medication, Midodrine, HCL, 5 mg, orally, every 8 hours as needed, hold the medication for a systolic blood pressure greater than 130 mm/Hg. Review of Resident #131's medication administration records (MAR) from 02/12 through 07/28/22, failed to reveal the nursing staff had administered a single dose to Resident #131.
February 2022, 9 AM Systolic BP readings included:
02/14 - 126, 02/15 - 127, 02/18 - 117, 02/20 - 110, 02/21 - 118, 02/22 - 108, 02/23 - 119.
February 2022, 5 PM Systolic BP readings included:
02/12 - 113, 02/13 - 104, 02/14 - 126, 02/15 - 127, 02/17 - 122, 02/18 - 128, 02/19 - 113, 02/21 - 120, 02/22 - 121, 02/23 - 128, 02/24 - 129.
April 2022, 9 AM Systolic BP readings included:
04/01 - 127, 04/06 - 127, 04/08 - 122, 04/10 - 127, 04/14 - 124, 04/19 - 125, 04/21 - 129, 04/22 - 128, 04/29 - 128, 04/30 - 121
April 2022, 5 PM Systolic BP readings included:
04/02 - 125, 04/03 - 127, 04/07 - 127, 04/10 - 127, 04/13 - 127, 04/14 - 124, 04/19 - 127, 04/22 - 127, 04/29 - 128, 04/30 - 121, 04/31 - 125.
Further review failed to reveal that staff were monitoring Resident #131's blood pressures at 1 AM nor did the nursing staff sign off they had administered a dose of Midodrine at 1 AM (every 8 hours) from 02/12 through 07/28/22.
Further review of Resident #131's closed medical record revealed a physician progress note, dated 07/12/22, and nurse practitioner notes, dated 05/16/22 and 05/24/22, all indicating Resident #131 was receiving the medication Midodrine every 8 hours and withholding the medication for a Systolic Blood Pressure greater than 130 mm/Hg.
Further review of Resident #131's closed medical record revealed a care plan for the indication of hypotension related to end stage renal disease that was initiated on 02/12/22.
10. Review of complaint MD00199200 on 11/07/23 revealed an allegation the nursing staff failed to accurately assess and intervene when Resident #108 had a change in condition. When 911 staff arrived at approximately 8:10 AM, 911 staff arrived, the facility staff reported to the 911 staff that there was nothing wrong with Resident #108. 911 staff spoke with the facility nurse and requested recent vital signs for Resident #108 and was informed that Resident #108's vital signs were fine. Unable to locate a recent of vital signs, the facility nurse obtained a new set of vital signs. 911 indicated Resident #108's vital signs were reported as: blood pressure 87/45, heart rate 50, respiratory rate of 22, and a finger stick glucose reading of 45 mg/dl. Resident #108 was moved to a stretcher and sent to the emergency room.
Review of Resident #108's medical record on 11/07/23 revealed that Resident #108 was admitted to the facility on [DATE] with diagnoses that include but not limited to anemia, bacteremia, psychoactive substance use, arthritis, and streptococcal sepsis. Resident #108's attending completed a MOLST form on 07/24/23 that indicated Resident #108 wants to be a Full Code and also wanted all life sustaining procedures. On 11/06/23 at approximately 8 AM, Resident #108's family member phoned 911 due to a change in condition in Resident #108's level of consciousness.
In an interview with staff member #98 on 11/07/23 at 10:45 AM, staff member #98 stated she arrived on the second floor at approximately 7:30 AM and observed Resident #108's family member was in Resident #108's room. Staff member #98 stated that she was informed by the night shift nurse that Resident #108's family member wanted Resident #108 to be transferred to the emergency room but earlier Resident #108 had refused to go. Staff member #98 stated that 911 had arrived and requested a set of recent vital signs for Resident #108. Staff member #98 stated that she had to obtain a new set of vital signs on Resident #108 and documented: a blood pressure 85/63, pulse rate 65, oral temperature 97.8, and an Oxygen saturation 98%. Staff member #98 stated she also obtained a fingerstick glucose reading of 41 mg/dl. Staff member #98 stated that she went to get a dose of glucagon to administer to Resident #108 but there was none available on the first medication cart. Staff member #98 went to the second medication cart and was unable to find a dose of glucagon on the second medication cart. Staff member #98 stated that she was unsure if a dose of glucagon was available in the second-floor medication room. Staff member #98 stated 911 staff notified that they would address Resident #108's reading of 41 mg/dl and emergently transferred Resident #108 to the emergency room.
Further review of Resident #108 medical record failed to reveal a nursing assessment and a set of vital signs prior 911 intervention and being taken emergently to the emergency room.
Based on clinical record review, review of complaint intakes, observation, and staff interview it was determined that the facility staff failed to ensure residents received quality care regarding, but not limited to, medication administration, catheter care, conduct and document accurate nursing assessment, promptly identify and intervene for an acute change in a resident's condition and to provide an emergency medication (Glucagon) timely to a resident (Resident #108) with a finger stick result of 41mg/dl. This was evident for 10 (#121, #161, #364, #381, #63, #16, #517, #162, #131, and #108) out of 140 residents in the survey sample for the annual recertification and complaint survey.
The findings include:
1. A review of Resident #121's clinical record on 10/30/23 as part of the investigation into intake #00191930 revealed the resident had a follow up Angiogram (a scan that shows blood flow through circulatory system) scheduled for 1/23/23 at a hospital. The resident was unable to go to the appointment because the resident requires ambulance transportation and transfers using a Hoyer lift which was broken at the time of the appointment. The appointment was rescheduled for 2/6/23.
A review of the resident's Medication Administration Audit Report (MAAR) on 11/17 and 11/18/23 revealed that the resident had several medications administered outside of the prescribed time. The resident was admitted on [DATE]. The resident was prescribed Lidocaine patches (treats pain) for both knees to be applied at 9:00 AM but they were not applied until 11:26 AM. Metoprolol (blood pressure medication) was ordered for 9:00 AM but not administered until 11:27 AM. Clopidogrel (prevents clotting) was ordered for 9:00 AM but not administered until 11:26 AM. Triumeq (treats HIV) was ordered for 9:00 AM but not administered until 11:27 AM.
The third floor Unit Manager (Staff #3) was interviewed on 11/3/23. He stated it is his responsibility to follow-up on new admissions, and to ensure orders are written/transcribed accurately.
2. Resident #161's clinical record was reviewed on 11/14/23 as part of the investigation into intake #MD00177440. The resident was admitted on [DATE] but medications were not started until 12/30/21 and were administered 2-4 hours past the ordered time.
Prednisone 10 mg (treats inflammation) and Zyprexa 5 mg (helps mental health) were ordered to be administered at 8:00 AM but were not administered until 12:16 PM.
Metoprolol 50 mg (blood pressure medication) was ordered to be administered at 9:00 AM but not administered at all.
Medications ordered to be administered at 9:00 AM but not administered until 12:16 PM: Multi Vitamin, Folic acid 1 mg, Vitamin D3, Apixaban 5 mg (anticoagulant), Depakote 250 mg (treats bipolar disorder), Senokot 1 tab, Haloperidol 5 mg (treats mood), Hydroxycholoroquine 200 mg (treats Lupus), FerrouSul 325mg, Docusate 100 mg, and Nifedipine 90 mg (treats hypertension).
Levothyroxine (treats thyroid) 25 mcg ordered to be administered at 10:00 AM but not administered until 12:17 PM.
Administrator informed of findings on 11/17/23 at 1:30 PM. No evidence provided prior to exit.
3. Resident #364's clinical record was reviewed on 11/8/23. Resident was admitted on [DATE] at 9:30 AM. Some medications were not administered until later in the day or not until 10/1/22.
Resident's physician ordered Albuterol (treats asthma) 2 puffs twice a day and Fluticasone (treats asthma) 2 puffs twice a day, both ordered for 8:00 AM and 8:00 PM but neither administered on 9/30/22.
Metanx (treats diabetes) 1 capsule twice a day was ordered to be administered 9:00 AM and 5:00 PM but not administered on 9/30/22.
Cefepime (treats osteomyelitis) 1 gm was ordered to be administered every 6 hours and was administered at 12:00 PM but not at 8:00 PM on 9/30/22.
Administrator informed of findings on 11/17/23 at 1:30 PM. No evidence provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pain management is an aspect of medicine and health care involving relief of pain; the process of providing medical care that al...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pain management is an aspect of medicine and health care involving relief of pain; the process of providing medical care that alleviates or reduces pain.
Analgesic is a medication that relieves pain.
3. On 9/27/2023 at 9:50 AM, review of Resident #517 electronic medical record confirmed that the resident was admitted on [DATE] with diagnoses that included but not limited to ESRD (end stage renal [kidney] disease), dependence on renal dialysis, osteomyelitis (bone infection), laminectomy, fusion of spine, hypertension, hypoglycemia, and chronic postprocedural pain.
On 9/29/2023 at 10:34 AM during an interview with Resident #517, resident stated I'm waiting for my meds (pain medication) since I've been back from the hospital. I haven't had my meds yet this morning or last night. They told me because I was discharged I couldn't get my meds. Resident told surveyors his/her pain score was a 7.
On 10/3/2023 at 9:00 AM, surveyors conducted a review of Resident # 517's medical record, which revealed a pain evaluation conducted 9/29/23 at 11:30 AM which revealed that pain was noted frequently and limits day to day activities, he/she vocalized pain at 9 and stated pain was relieved with medication.
Surveyors toured the unit on 10/4/2023 at 6:40 AM. While on tour, the surveyors conducted an interview with Licensed Practical Nurse (LPN), who revealed to surveyors that Resident # 517 was returned to the facility from the hospital on [DATE] at 7:30 PM.
On 10/10/2023 at 9:45AM, during an interview with Resident #517, the resident stated I have not received my pain medication since I came back here (facility) from the hospital on October 3rd. They (nurses) said I have to ask for it.
10/10/2023 at 10:00AM, review of electronic medical records showed that the resident reported experiencing pain (at the back of the neck near the surgical incision site) occasionally and the pain can limit day to day activities.
Further review into the resident's medical record revealed pain medications were not available to Resident #517 from 10/4/2023 at 12:40 AM to 10/6/2023 at 2:15 PM.
An order for a controlled drug that is used to relieve pain, which read: Give one 10 mg (milligram) tablet, by mouth every 6 hours as needed for pain was noted as having a start date of 10/6/2023.
Additional review of Resident #517's medical record revealed an order for a pain evaluation to be conducted every shift to assess for pain. This order was initiated on 10/3/2023.
Surveyors noted the following documentation listed under, Pain Assessment on the electronic medical record, that showed Resident #517 reported being in pain. Resident# 517's pain assessment scores were documented as follows, a pain score of:
7 on 10/4/2023 at 3:36 AM
9 on 10/5/2023 at 11:51 AM
6 on 10/6/2023 at 5:50 AM
8 on 10/7/2023 at 1:58 PM
6 on 10/8/2023 at 6:13 AM
7 on 10/9/2023 at 3:08 AM
7 on 10/9/2023 at 5:40 AM
9 on 10/19/2023 at 12:36 AM
A pain assessment scale measures a patient's pain intensity from 0 representing ' no pain at all ' through 10 representing ' the worst pain ever possible ' .
According to the resident's medication administration record for the month of October 2023, pain medication was ordered on 10/6/2023 for the resident yet, not documented as administered to the resident until 10/9/2023.
During continued review of Resident #517's electronic medical record, surveyors noted a care plan created on 10/4/2023 to address Resident # 517's chronic pain (located at the back of the neck). The care plan included interventions to administer analgesic(s) as ordered and to monitor, record, and report to the nurse resident ' s complaints of pain or requests for pain treatment.
On 10/10/2023 at 12:19, during an interview with interim DON, it was reported that the expectation is that pain medication will be ordered immediately after the resident is admitted to the facility.
On 10/11/2023 at 12:35 PM, surveyors conducted an interview with Physician, Staff #50. Staff #50 stated that she assessed Resident #517 on 10/5/2023. Following the assessment, Staff #50 ordered an analgesic for pain on 10/6/2023. Surveyors made Staff #50 aware of the concerns that the resident's medical record did not show pain medication available to the resident from his/her readmission on [DATE] through 10/6/2023, and even once it was ordered on 10/6/2023, the pain medication was not administered as ordered for documented pain until a dose was administered on 10/9/2023. According to Resident #517 pain assessment documentation, he/she was experiencing pain from 10/4/2023 through 10/9/2023without pain relief.
On 10/18/2023 at 10:30 AM surveyors reviewed the concern with the Administrator and the interim DON regarding the failure to ensure that Resident #517 received timely pain medication when experiencing pain. The facility staff did not provide any additional documentation regarding the missed opportunities to provide the resident with any pain relief
Surveyors made concerns known to the facility administrator, interim DON, and the Regional Director of Clinical Operations throughout the survey and again during exit conference.
2. On 10/05/2023 at 9:00 AM, a medical record review revealed that Resident #63 had an order that had been active since 05/11/2023, for oxycodone HCL, an opioid pain medication. The instructions read give 2 tablets by mouth every 4 hours for pain 7-10.
A review of Resident #63's medication administration records revealed that in August 2023 oxycodone was administered 15 times for a pain score below a 7. In September 2023 oxycodone was administered 42 times for a pain score below 7.
On 10/05/2023 at 11:00 AM, Staff #24, a nurse, stated If there's parameters a [nurse] can't give outside of pain scale parameters.
On 10/05/2023 at 11:22 Staff #39, a Regional Nurse, and Staff #3, a Unit Manager, were made aware of the findings. Staff #3 explained that Resident #63 could have been given the medication outside of parameters because the resident intimidates my staff.
Facility pain management policy reads that opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences. Dosing outside of prescribed parameters does not meet professional standards of practice.
Based on clinical record review, observation, and staff interview it was determined that the facility staff failed to appropriately administer pain medications as ordered. This was evident for 3 (#15, #63, and #517) residents out of 11 residents reviewed for pain management.
The findings include:
1. A review of Resident #15's clinical record on 10/5/23 revealed the resident was prescribed Oxycodone 7.5 mg every 4 hours as needed for pain.
A review of July 2023's Medication Administration Record (MAR) revealed the resident rated their pain as a 0 on a 0 to 10 scale on July 24, 2023, at 5:25 AM. The resident received a dose of pain medication to treat the presumed absence of pain.
A review of August 2023's MAR revealed the resident rated their pain as a 0 at 2:56 AM and 7:19 AM but still received the Oxycodone.
A review of September 2023's MAR revealed the resident rated their pain as a 0 at 1:55 AM on 9/20/23 and at 6:25 PM on 9/21/23.
The Director of Nursing (DON) was interviewed on 10/5/23 at 12:25 PM. This surveyor asked what a nurse should do if as needed pain medications did not include a pain scale to tell nurse when to administer. She replied that the nurse should have called the physician for a pain scale to tell her when she should administer. If the resident says they are in pain but rate pain as 0 out of 10 then she would expect them not to administer. She looked at each example to determine which nurse(s) are responsible.
The survey team interviewed the DON on 10/10/23 at 12:18 PM. She said the initial order for medications should be put in when the resident arrives. When a resident is in pain but there is no pain scale when would you expect them to administer the medicine? She replied, they should be using a pain scale that the resident can understand. If there is not a level ordered, then the order needs to be clarified. The medication should not be given if pain is rated as a 0 on a pain scale where zero means no pain.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record reviews, and staff interviews it was determined that the facility staff failed to put a system in place to ensure that prescribed medications are correctly transcribed and administered...
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Based on record reviews, and staff interviews it was determined that the facility staff failed to put a system in place to ensure that prescribed medications are correctly transcribed and administered. This was evident for 1 (Resident # 46) of 1 residents reviewed for medication administration concerns during the survey.
The findings include:
Polyneuropathy is a condition in which a person's peripheral nerves are damaged. It affects the nerves in your skin, muscles, and organs. When these nerves are damaged, they can't send regular signals back to your brain.
A review of the medical record to investigate intake # MD00196805 was conducted on 10/25/2023 at 10:15 AM. revealed Resident # 46 was admitted to the facility with diagnosis that included Polyneuropathy, nerve pain, and kidney failure requiring dialysis.
A review of the resident's Medication Administration Record (MAR) on 11/2/23 at 08:00 AM revealed an admission order dated 06/22/23 for Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth one time a day every Mon, Wed, and Fri for nerve pain; To be given after dialysis. However, further review of the monthly MARs showed that Resident #46 had received Gabapentin 3 out of 7 days per week since their June 2023 admission. Further review of the Gabapentin monthly administration record found 74 missed doses from June 24, 2023, through November 3, 2023.
During an interview with Resident #46's physician (staff # 50) on 11/02/23 at 10:15 AM it was revealed that it was expected that all admission orders are reviewed at least twice, once by nursing and the other by a physician. Staff #50 added that the nursing staff reviews can be completed with the physician over the phone.
According to Resident # 46's Nursing Unit Coordinator (staff#3) during an interview conducted on 11/03/2023 at 1:45 PM, he performed daily reviews and reported any discrepancies he found to the residents' physician and the Director of Nursing. He also indicated that it was his responsibility to oversee physicians' order management and monitoring by daily progress notes and physicians' order reviews that included a review of all new admissions' documentation to ensure that orders are written and transcribed accurately and administered to residents accordingly. This was conducted through the reviews of all MARs and Treatment Administration Records and provided notifications to pharmacy for needed corrections associated with them. He also provided staff education as needed. During the interview he confirmed he knew Resident #46. When asked he stated he has been doing the reviews but never found any issues with Resident #46's medication orders.
During the interview staff #3 reviewed Resident #46's admission order for Gabapentin and the transcribed administration instructions on the June 2023 - November 2023 MARs shared by the surveyor. Staff #3 acknowledged that the admission orders for the Gabapentin's, administration, and the monthly MARS transcriptions were inaccurate, should have been reviewed, and verified by the resident's physician before transcribed and checked by nursing for accuracy before administrating the medication to the resident. He also acknowledged the undetected inaccurate orders and MARs for Resident #46 caused continuous medication errors that resulted in the 74 missed doses from June 2023 through November 2023.
During a follow-up interview with Staff # 50 on 1/07/23 at 2:00 PM, when asked she stated Staff #3 had made her aware of the inaccurate order and dosage frequency transcription errors for Resident #46's Gabapentin medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews it was determined that the facility failed to ensure: 1) appropriate temperature was mainta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews it was determined that the facility failed to ensure: 1) appropriate temperature was maintained for the medication refrigerator and 2) expired medications were properly disposed of and 3) narcotic medications were adequately wasted, and 4) to maintain a safe and effective system for securing medications and treatments in designated carts on the nursing unit. This was found to be evident in 2 out of 3 medication storage rooms observed in the facility and 2 of 3 medication carts observed out of 6 medication carts in the facility.
The findings include:
1. On 10/05/2023 at 8:16 AM the surveyor and Unit Coordinator, Staff #21, conducted an observation of the 4th floor medication storage room located behind the nurses station. The surveyors found the refrigerator's thermometer located inside of the refrigerator, on the top shelf of the door, with a temperature reading of 52 degrees Fahrenheit. The medication refrigerator log stated a minimum temperature of 36 degrees Fahrenheit and a maximum of 46 degrees Fahrenheit.
2. On 10/05/2023 at 8:25 AM the surveyor and Staff #21 observed inside of the refrigerator and found: Four 100 ml (milliliter) bags of Normal Saline with Cefepime labeled Do Not Refrigerate.
Found on the shelf in the medication storage room labeled Refrigerate were: Seven clear 500 ml bags of normal saline with added {antibiotic} which labeled discard after 10/01/2023, One 100 ml bag of normal saline with added {antibiotic} labeled discard after 9/29/2023, Three 100 ml bags of normal saline with added {antibiotic} labeled discard after 10/02/2023, One 250 ml clear bag of normal saline with added {antibiotic} labeled- expiration date of 10/1/2023, Three 100 ml bag of normal saline with added {antibiotic} with expiration date 10/5/2023. Two 100 ml clear bags with added {antibiotic} labeled expiration date of 10/01/2023, One 440 ml container of sterile water opened with open date 10/3/23 and access device attached to the bottle.
On 10/5/2023 at 10:10 AM the interim DON was made aware of the findings and confirmed that education would be conducted with the Unit Managers and licensed nurses on appropriate storage of medications.
On 10/18/2023 at 8:06 AM surveyors and Unit Manager, Staff #24, observed the refrigerator on the 3rd floor storage room and found: One 500 ml clear bag of normal saline with added Vancomycin labeled Discard after 10/15/2023, Three clear 500 ml bags of Vancomycin labeled Discard after 10/17/2023.
Found on the shelf in the medication storage room was one 4 ounce (oz) tube of sterile lubricating jelly- opened with no open date noted.
3. On 10/12/2023 at 11:50 AM during observation of medication storage, surveyor and Staff #25 identified a bottle of {opioid} labeled for Resident # 215 double locked in the medication cart with date 10/8/2023. The instructions on the Medication Chain-of- Custody Record for {opioid} stated: Note: Please pay attention to days given as bottles are dated due to tapering dosing. Give on Dates.
In a subsequent interview with Staff # 25, he revealed that the {opioid} should have been wasted since Resident # 215 was out of the facility at an appointment on 9/22/2023. Staff #25 goes on to say: The wellness coordinator and the physician should have been notified of the missed dose and then the {opioid} should have been wasted with two nurses signing for it.
The identified concerns were reviewed with the interim DON, Regional Director of Clinical Services (RDCO), and the Administrator throughout the survey and again during the survey exit conference.
6. On 09/27/2023 at approximately 9:27 AM, the surveyor observed an unlocked and unattended medication cart located on the 4th floor nursing unit. The surveyor was able to open each medication drawer that had labeled medications packets with the resident's name and room number, insulin pens, in-house liquid medications, and eye drops. At approximately 9:30 AM the surveyor observed Registered Nurse (RN) #1 walk out of Resident #420's room.
During an interview conducted on 09/27/2023 at approximately 9:30 AM, RN#1 stated Resident #420 had requested care, she left the medication cart to provide care for the resident and failed to lock the medication cart prior to entering the resident's room. The RN further stated the facility's policy was to always lock the medication cart when unattended.
On 09/28/2023 at approximately 10:05 AM, the surveyor observed an unlocked and unattended medication cart located on the 4th floor nursing unit. The surveyor was able to open each medication drawer that had labeled medications packets with the resident's name and room number, insulin pens, in-house liquid medications, and eye drops. At approximately 10:09 AM the surveyor observed License Practical Nurse (LPN) #42 return to her assigned medication cart.
During an interview conducted on 09/28/2023 at approximately 10:09 AM, LPN #42 stated she made a mistake and left her medication cart unlocked. The LPN further stated that the facility's expectation is to always lock your assigned medication cart when unattended.
During a random observation on the 4th floor nursing station on 10/16/2023 at 10:40 AM, this surveyor observed an unlocked treatment cart. The surveyor was able to open each drawer of the treatment cart, the items located in the treatment cart that had 2 pairs of scissors, 2 containers of silver nitrate, gauze, ace bandages, ABD pads, aqua derm, border foam, and aquacel.
During an interview on 10/16/2023 at approximately 10:42 AM Registered Nurse #59 stated she was not aware the treatment cart was unlocked. The surveyor observed the RN lock the treatment cart, the RN stated the facility's policy is to lock the treatment cart after removal of the supply.
4. During an observation of the second-floor nurses' station on 11/06/23 at 9:40 AM, the nurse surveyor observed a large white pill lying on the floor behind the nurses' station. The pill was picked up and given to the second-floor Nurse Manager. The Nurse Manager stated that he had not received any reports of medications lying on the floor behind the nurse station.
5. During an observation of room [ROOM NUMBER] on 11/06/23 at 9:50 AM, the nurse surveyor observed a medication cup filled with 5 pills sitting on the resident's bedside table. Resident #52 was asleep in the bed. The nurse surveyor summoned staff member #98 to Resident #52's bedside and informed the nurse of the observation. Staff member #98 indicated that she was passing medications to the other side of the unit at the time. Staff member #98 attempted to awaken Resident #52 but Resident #52 just turned over and pulled the bed cover over his head. Staff member #98 removed the cup of medications from Resident #52's bedside.
In an interview with staff member #37 on 11/06/23 at 9:50 AM, staff member #37 stated that she was just returning from a break and that she was the nurse responsible for leaving Resident #52's cup of medications on the bedside table. Staff member #37 confirmed that she left Resident #52's medications on the bedside without administering them.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 9/28/2023 at 8:33 AM, during record review, surveyors discovered Resident #517, was transferred to the emergency room due ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 9/28/2023 at 8:33 AM, during record review, surveyors discovered Resident #517, was transferred to the emergency room due to hypoglycemia (low blood sugar) on 9/27/2023 at 11:05 AM, shortly after being taken to the dialysis clinic within the facility.
Further review of the medical record revealed that Resident #517 was admitted to the facility 9/25/2023 with diagnoses of, but not limited to, ESRD (end stage renal [kidney] disease), dependence on hemodialysis, hypoglycemia, osteomyelitis (bone infection), post procedural pain, heart failure, and high blood pressure.
On 9/29/2023 at 11:45 AM, Surveyors reviewed Resident #517's active orders since Resident #517's initial admission to the facility and noted that there were no active physician orders addressing: 1) the resident's need for continued nutritional monitoring, blood sugar level monitoring, the addition of cornstarch or a complex carb for maintaining steady blood sugar levels and 2) the need for care for and the location of the resident's indwelling catheter, and dialysis access site as part of his/her medical record.
On 9/29/2023 at 1:09 PM, during record review, Surveyors discovered an order created 9/29/2023 at 11:22 AM for Resident #517 to be sent out to the hospital immediately. The resident was transferred to the hospital due to another episode of low blood sugar.
During an interview on 10/4/23 at 6:40 AM, Licensed Practical Nurse (LPN), Staff #6, revealed to the surveyors that the admission Nurse is responsible for reviewing the discharge summary and then adding the orders into the electronic medical record. The Unit Manager is supposed to check and make sure they are complete and accurate prior to the physician verifying and then signing the orders in the electronic medical record. The surveyors asked if there is an admission policy or procedure to follow which guides the nurses and Staff #6 states we want an admission resource binder to help us, especially new nurses and agency nurses. She informed the surveyors that there is nothing on the unit to give us guidance for the new admission process or a checklist to make sure everything is completed for the resident at admission. She went on to say that when Resident #517 was readmitted on [DATE], his/her orders were entered in his/her electronic medical record on 10/3/2023-10/4/2023 by Registered Nurse (RN), Staff # 107.
On 10/4/2023 at 11:45 AM, the Administrator was made aware of the concern that Resident #517's hospital discharge recommendations were not thoroughly reviewed and accurately documented into the resident's medical record at initial admission to the facility and after subsequent admissions. Surveyors informed the Administrator that Resident #517 received specific care instructions listed in the discharge summaries from each hospitalization that the facility staff failed to acknowledge, initiate, and therefore implement within his/her plan of care from admission on [DATE]-[DATE]. Administrator stated that education will be provided to all licensed nursing staff on accurate documentation into residents' records.
On 10/5/2023 at 9:30 AM, surveyors reviewed Resident 's #517 electronic medical record and discovered discharge instructions to include that the resident was to remain on a renal diet with complex carbohydrates: 5 meals a day (Encourage 5 meals a day {3 full meals with 2 snacks}) with carbohydrates (Cornstarch) to help with hypoglycemia. Surveyors reviewed residents medical record and did not find a active diet order for Resident #517 as of that time.
On 10/10/2023 at 9:30 AM, surveyors conducted an interview with the Certified Dietary Manager, Staff # 94. He stated that there is a Diet Order and Communication form (on paper) which the nursing staff completes to inform him of any new dietary orders regarding the residents. The new orders are updated in the kitchen system, which is different from the facility. Staff # 94 had not received a Diet Order and Communication form for Resident #517.
10/10/2023 at 9:42AM, surveyors interviewed LPN, Staff #43. Staff #43 reviewed Resident #517's electronic medical record and was unable to locate Resident #517's diet order. Staff #43 went on to confirm the expected facility's practice was to document the resident's diet order on the resident's electronic record and to submit a completed Diet Order and Communication form (on paper).
On 10/10/2023 at 10:25AM, an interview was conducted with the Registered Dietitian (RD), Staff #41. During the interview, Staff #41 stated that diet orders are put into the electronic medical record by nursing staff and reviewed by the physician and himself. He acknowledged that Resident #517 did not have a diet order since readmission [DATE] and verified a diet order added 10/10/2023.
On 11/17/2023 at 12:30 PM, the facility Administrator, the Registered Dietitian, and the Regional Director of Clinical Operations were made aware of the concern for accurate and thorough implementation of physician orders upon a resident's admission to the facility. No additional documentation was provided regarding this concern.
2. Observation, on 09/27/23 at 1:08 PM, the surveyor was unable to locate Resident #8 by looking at the name labels on outside of the residents' rooms on 2nd floor unit.
Record review, on 09/27/23 at 2:05 PM Resident was recently transferred from 411-A to 222-A.
On 10/03/23 at 9:10 AM the surveyor observed the name label outside of room [ROOM NUMBER], discovering only one, Resident #95's, name on display. Entered the room and discovered two Residents in the room (Resident 95 # and #8). Observed 2 more rooms: 223 and 224 also missing name labels (223's Resident #79 and 224's Resident #64) on the outside of their rooms. An interview was conducted with the Geriatric Nursing Assistant (GNA) Staff #63, she was aware that the name labels for residents # 8, #79 and #64 were still missing. Staff #63 stated that if a resident's name label was missing then it must be reported to Staff #32 or the admission office to correct it immediately.
The Geriatric Nursing Assistant (GNA) works directly with elderly patients to ensure their comfort and well-being.
Interview, on 10/03/23 at 09:23 AM, altered the Unit Manager (Staff #32) above findings and he was unaware that residents' name labels were missing. From a floor census that he provided, two residents were listed in room [ROOM NUMBER]: Resident 95 # and #8.
Based on observation, interviews, review of a complaint, review of administrative documents and record review, it was determined that the facility failed to keep accurate resident records in accordance with professional standards, to accurately display residents' names outside of their rooms, and to ensure that when the nursing staff destroy Schedule II medication, the administrative records were accurate. This was evident of 5 out of 140 (Resident #22, #8, #79, #64, #517, and #162) residents reviewed for accuracy of documentation on annual and complaint survey.
The findings include:
1. On 9/28/23 at 11:45 AM, the surveyor conducted an interview with Resident #22. During this interview Resident #22 stated he/she did not have any teeth but also indicated he/she did not have any trouble eating with the lack of teeth. The surveyor observed Resident #22 confirmed that he/she did not have any teeth.
On 10/4/23 at 11:44 AM, the surveyor interviewed Speech Therapist Staff #36. During this interview Staff #36 confirmed that she evaluated Resident #22 in early January and Resident #22 did not have any teeth or dentures.
On 10/5/23 at 8:09 AM, the surveyor reviewed the medical record for Resident #22. The review revealed that on 1/10/23, 5/1/23 and 6/12/23 the admission/readmission evaluation documented that Resident #22 had his/her own teeth and indicated Resident #22 had no missing teeth.
Further review revealed that Resident #22 had a Minimum Data Set (MDS) assessment completed on 1/17/23 that documented Resident #22 as having no natural teeth or tooth fragments, also known as edentulous. The 3 admission evaluations were not consistent with Resident #22 other assessments.
4. A review of complaint MD00198126 on 10/26/23 revealed an allegation Resident #162 had not received medications timely.
A review of the facility's Controlled Substance Administration & Accountability policy on 10/26/23 revealed under section 4 - Obtaining/Removing/Destroying Medications, d. Two licensed staff must witness any disposal or destruction of a controlled substance and document the same on the Drug Disposition Record.
A review of Resident #162's closed medical record on 10/26/23 revealed that Resident #162 had been admitted to the facility on [DATE] with diagnoses that included: metabolic encephalopathy, liver abscess, diabetes, and sepsis. Resident #162 was discharged on 10/17/23.
A review of Resident #162's schedule II narcotic administration record on 10/26/23 revealed that the former Director of Nurses (DON) had independently destroyed 34 tablets of 5 mg Oxycodone on 10/16/23. The former DON was the only licensed staff member witnessing the Oxycodone destruction.
In an interview with the 3rd floor Unit Manager on 10/27/2023 at 5:15 PM, the 3rd floor Unit Manager stated that upon discharge, the resident's medications are removed from the medicine cart and are to be destroyed right away. There should be 2 nurses to witness the destruction with the signatures of the 2 nurses. Review of Resident's 2 medication monitoring control records for Resident #162 only revealed the former DON's signature.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected multiple residents
Based on interviews, and review of employee records, it was determined that the facility failed to have a qualified, full-time Social Worker employed to oversee the social service duties. This was fou...
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Based on interviews, and review of employee records, it was determined that the facility failed to have a qualified, full-time Social Worker employed to oversee the social service duties. This was found evident during 5 months in 2022.
The findings include:
On 10/13/23 at 1:47 PM, the surveyor reviewed staff records from the human resource department. The review revealed that Social Service Director Staff #95 was employed as the facility's Social Service Director from 9/3/21-3/4/22. Staff #95 has a bachelor's degree in social work and was licensed in the State of Maryland as a Social Worker. The next Social Service Director hired by the facility was Staff #96. Staff #96 did not have a bachelor's degree. Further review revealed that Staff #96 stopped working as the Social Service Director on 5/1/22. The next Social Service Director the facility hired was Social Service Director Staff #14 and was hired on 9/6/22.
The review of the records revealed that there was no qualified social worker employed at the facility from 3/5/22-9/5/22.
On 11/16/23 at 1:47 PM, the surveyor conducted an interview with the Nursing Home Administrator (HNA). During this interview the NHA acknowledged there were months without a qualified Social Worker at the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2b.) During an initial tour of the facility conducted on 09/27/23 at 10:40 AM, Resident #59 was observed standing in the doorwa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2b.) During an initial tour of the facility conducted on 09/27/23 at 10:40 AM, Resident #59 was observed standing in the doorway of his/her assigned room on the 4th floor. Further observation of Resident #59's room revealed a mattress on the floor, chipped paint under the window sill, and a damaged, nonfunctional air conditioning (A/C) / heating unit with no front cover panel and exposed metal pieces. The bathroom had a strong smell of urine and sewage and the toilet bowl was full of brown water.
On 09/27/23 at 10:42 AM an interview conducted with Housekeeper #88 revealed that she was responsible for cleaning the 4th floor, including Resident #59's bathroom. Housekeeper #88 stated she was aware of the clogged toilet and had already reported it to her supervisor a few times but nothing was done about it.
TELS Platform is the #1 web-based software designed to help Senior Living operators and maintenance teams drive efficiency and cost savings.
During an interview conducted on 09/28/23 at 09:03 AM, Maintenance Director #7 stated that he had been working in this role for two months and that Environmental Services (EVS) was added to his responsibilities about one week ago. Maintenance Director #7 stated he is still learning how to work TELS, the facility's building management platform system, and that he is able to receive and view work order requests directly from his handheld device. He further stated that nurses are responsible for placing work order requests in the TELS system. Maintenance Director #7 stated he did not see any recent work order requests for Resident #59's bathroom in TELS at the time of this interview.
On 09/28/23 at 10:45 AM, an interview conducted with the Administrator revealed that the facility is currently in the process of being remodeled, however no work had been done on the 4th floor. The Administrator stated that Resident #59's mattress was placed on the floor as a safety precaution. He also stated Resident #59 had a history of tearing up his/her clothes and flushing them down the toilet which caused the room to flood. The Administrator stated that he was aware of the broken and damaged A/C/ heating unit in the room but that it was not plugged in.
On 09/28/23 at 11:47 AM, surveyors observed Maintenance Assistant #66 working in Resident #59's bathroom. Maintenance Assistant #66 stated he needed to snake the toilet, however the water supply to the Resident #59's bathroom had been shut off and he would need to contact his supervisor for what to do next.
In a follow up interview conducted on 09/28/23 at 12:45 PM the Administrator stated that Resident #59 would be moved into a new room.
On 10/04/23 at 09:12 AM, surveyors observed Resident #59 in his/her newly assigned room. Resident #59 was resting quietly in an electric hospital bed that was dressed with clean linen, there was no chipped paint on the walls, and the A/C heating unit was functional and in good repair. The bathroom toilet was not clogged and the water was clear. The room did not smell of urine or sewage.
Multiple follow up observations conducted throughout the survey of Resident #59's living area revealed no evidence of damaged, nonfunctional equipment, toilet issues or any foul smells.
Based on observations, interviews, and record review, it was determined that the facility failed to; 1) keep a sanitary environment. This was found evident on 1 out of 3 floors observed and 2) failed to keep a functional and comfortable environment for 2 of 2 (Resident #84 and #59) random rooms observed on an annual and complaint survey.
The findings include:
1.) On 10/5/23 at 11:41 AM, the surveyor observed a partially-eaten food tray labeled breakfast in room [ROOM NUMBER]. No residents were in the room and the tray was left on the resident's bedside table. Next the surveyor observed a food tray located on top of a storage bin where personal protective equipment (PPE) and isolation equipment was stored. This bin was out in the hallway between room [ROOM NUMBER] and 210. On closer observation the tray was labeled breakfast and food had been eaten off the tray. A fly was noted flying over the tray.
On 10/5/23 at 11:44 AM, the surveyor interviewed Geriatric Nursing Assistant (GNA) Staff #99. During this interview Staff #99 was asked if he knew why the consumed breakfast tray was in the hallway. He stated sometimes the Resident puts it there. He confirmed that it should not be there and removed the tray.
On 10/17/23 at 9:15 AM, the surveyor observed Licensed Practical Nurse (LPN) Staff #23 walk into Resident #39's room. Staff #23 then left Resident #39's room with Resident #39's food tray and placed the tray on a storage container in the hallway that was holding PPE and isolation supplies.
After this observation the surveyor interviewed Staff #23. She confirmed the food tray did not belong in the hallway on the storage bin and removed the food tray.
On 11/1/23 at 6:06 AM, the surveyor observed a food tray outside room [ROOM NUMBER] in the hallway. On further observation the surveyor noted the tray was labeled supper and dated 10/31/23. No food seemed to be eaten and the tray was on top of the PPE storage bin.
On 11/1/23 at 6:13 AM, the surveyor observed a plate with remnants of a salad on it. This plate was placed inside a plastic garbage bag and was observed in the hallway on top of a PPE storage bin by room [ROOM NUMBER].
On 11/01/23 8:42 AM, the surveyor again observed the plate in the bag outside room [ROOM NUMBER].
On 11/16/23 at 1:47 PM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). The surveyor reviewed the multiple observations of food trays being left out in the hallway on the second floor.
2a.) On 10/24/23 at 12:14 AM, the surveyor conducted an interview with Resident #84. During the interview Resident #84 reported that he/she had switched rooms before the weekend and stated nobody helped put any of his/her belongings away. Resident #84 further stated that his/her current closet did not have a rod for hanging clothes and reported the facility staff placed his/her hanging clothes on the floor of the closet.
The surveyor observed three bags of belongings on a chair located in the room and a wheelchair. On further observation the surveyor opened the closet door and noted clothes on hangers on the floor of the closet. The rod in the closet was missing.
On 10/24/12 at 12:19 PM the surveyor interviewed Licensed Practical Nurse (LPN) Staff # 37. During this interview Staff #37 stated all Resident rooms should have a bed, storage chest/dresser, and a closet. Staff #37 agreed the closet should have a place for clothes to be hung.
On 10/24/23 at 12:21 PM, the surveyor interviewed Registered Nurse (RN) Staff #100, who was assigned to Resident #84. Staff #100 stated he/she was not aware the closet was not functional and would let maintenance know. Staff #100 stated she would also speak with assigned Geriatric Nursing Assistant (GNA) to assist Resident #84 with placement of his/her items.
On 10/24/23 at 12:31 PM, the surveyor conducted a record review of Resident #84's medical record. The review revealed a note written by Staff #37 on 10/20/23 at 11:20 PM stating Resident #84 had a room change and was oriented to the room and floor. The note confirmed that Resident # 84 had moved 4 days earlier and his/her belongings were not unpacked and closet rod was not addressed even after Resident #84's clothes that were on hangers were placed on the bottom of the closet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility's staff failed to ensure a sanitary and safe interior en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility's staff failed to ensure a sanitary and safe interior environment. This was evident for 1 (Resident#4) out of 8 residents reviewed for sanitary and safe environment.
The findings include:
Observation, on 09/28/23 at 12:31 PM the bathroom in room [ROOM NUMBER] found a pile of used paper towels under the sink, one ceiling tile that was off the ceiling track, and divided curtains between 2 beds that were torn. In addition, the inside of the bathroom door at the bottom had wood missing across the whole door.
On 10/02/23 at 10:13 AM an interview was conducted with the Maintenance Director (Staff #7) and Housekeeping (Staff #4), both stated they were making their daily rounds in residents' rooms; however, they were not aware of the above-described findings.
On 10/03/23 at 8:54 AM the surveyor observed the bathroom with the loose ceiling tile, the torn curtains and the damaged bathroom door which were left in the same condition. Staff #7 was notified again of the not acceptable findings in room [ROOM NUMBER].
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. T...
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Based on observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen.
The findings include:
During the initial tour of the kitchen conducted on 09/27/2023 at 7:58 AM, the Surveyor and cook #93 observed 3 bags of bread opened and undated on the bread rack. Further observations revealed 2 boxes of sausage opened and undated, 2 personal beverages (fruit punch and lemonade) opened and undated and 1 personal pan pizza undated and unlabeled on the top shelf in the walk-in freezer.
In an interview conducted on 09/27/2023 at 8:08 AM, the cook #93 confirmed the facility's food storage policy is to securely close packages/bags once opened and to label the package/bag with an open date and use by date with the date format of month, day and year.
During a continued tour of the kitchen, the Surveyor and cook #93 observed a black substance inside the far back top of the ice maker machine. [NAME] #93 stated that the ice machine stopped working a week ago and that the maintenance staff was responsible for checking the machine and weekly cleanings.
Wet nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. FDA guidelines mandate that all wares should be air dried. Using towels to dry dishes is never permitted.
Continued observations of the dish washing area revealed that the sink sanitizing solution parts per million (ppm) reading was low, registering at 200 ppm. This was verified by a strip test conducted by cook #93 at 8:17 AM, who stated that the sanitizing solution level is expected to be at 400 ppm. The Surveyor and cook #93 further observed gnats flying around, a large amount of food particles in the sink drain and wet nesting of 1 stock pot and 6 flat pans, in the dish washing area. [NAME] #93 stated that the exterminator came to the facility earlier in the summer to address the gnats but that the gnats were still an issue.
During a tour of the dry food storage conducted on 09/27/2023 at 8:24 AM, the Surveyor and Dietary Manager (DM) #94 observed 1 clear bag of unopened coconut flakes undated and unlabeled lying on the storage shelf. DM #94 stated that all unopened bulk food should be labeled with an expiration date once removed from its original box/container.
On 09/28/2023 at 1:32 PM, the Surveyor was provided with staff education records for in-services conducted by DM #94 for wrapping food items, sanitizer test strip range, personal food items, and wet nesting.
During a follow up kitchen tour conducted on 10/04/2023 at 10:12 AM, the Surveyor and DM #94 observed a storage rack in the food preparation area with multiple containers of dried herbs and seasonings that were not discarded by or before the expiration date. The food containers with expired dates were identified as follows: 1-16 ounce bottle of Ground Nutmeg with 3/24/23 open date 6/24/23 expiration date, 1-16 ounce bottle of Paprika with one illegible date, 1-16 ounce bottle of Whole Celery Seed with 3/24/23 open date 6/24/23 expiration date, 1-16 ounce bottle of Ground Ginger with no open date 3/12/21 expiration date , 1-16 ounce bottle of Ground Cumin with 3/16 open date 9/16 expiration date, 1-16 ounce bottle of Ground Allspice with 3/16 open date 9/16 expiration date, 1-16 ounce bottle of Thyme with 23 June 23 open date and 23 June 23 expiration date, 1-16 ounce bottle of Poultry Seasoning with 2/14/23 open date 8/14/23 expiration date, 1-16 ounce bottle of Mediterranean Style Ground Oregano with open date 9/8/23 and illegible expiration date and 1-16 ounce bottle of [NAME] leaves with open date 3/16 and 9/16 expiration date.
In an interview conducted on 10/04/2023 at 10:50 AM, DM #94 stated that the expired food items would be removed and discarded appropriately.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, it was determined that the facility administration failed to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by 1. Failure to ensure substantial compliance with regulations that were identified as deficient 2. Failure to implement plans of correction resulting in an immediate jeopardy for the safety of residents who required supervision while smoking by failing to adequately supervise those residents, 3. Failure to implement plans of correction related to residents ' behavioral health by failing to identify, monitor and prevent the additional occurrences of substance abuse, 4. Failure to provide oversight and monitoring of the maintenance and pest control plan of correction for the facility and the kitchen resulting in repeated citations of a non-homelike environment and unsanitary kitchen and food preparation area. The administration's failure to ensure processes were in place that could identify and correct deficient practice in care had the potential to adversely affect the health and safety of all the residents in the facility in addition resulted in an immediate jeopardy for the 3rd consecutive survey for the safety of residents regarding smoking and an actual harm regarding failure to identify and prevent additional occurrences of substance abuse in a resident with identified substance abuse disorder.
The findings include:
1. A. Review of the facility Substance use Tracking tool on 4/18/24 at 1:00 PM and an updated tool on 4/19/24 at 11:29 AM revealed that facility failed to include Resident #63 who was hospitalized on [DATE] and again on 4/9/24 for an overdose and reported suicidal ideations. S/he also had a positive urine toxicology for marijuana and cocaine reported to the facility on 4/12/24. Only the 4/6/24 incident was identified on the facility tracking tool. Additionally, on 4/17/24, a K-9 search of the facility identified multiple resident rooms with drug paraphernalia. Those
individuals were placed on the list provided to the team on 4/19/24. Those individuals were not on the list provided to the team on 4/18/24. The survey team was told by the facility Director of Nursing on 4/19/24 at 12:10 PM that the reason the residents were not on the tracking tool provided to the survey team on 4/18/24 was that the items confiscated were not logged and cataloged yet by the wellness director, staff #10 who was off on 4/18/24. The survey team asked where all the items they found were located. She stated they were locked in staff #10 's office, again who was off on 4/18/24.
B. Review of the residents placed on the Substance use tracking tool also failed to reveal consistency in the orders related to ongoing monitoring for the prevention of further occurrences for substance use. According to the facility DON, Regional Director of Operations (RDO) and RN staff #14 who were interviewed on 4/22/24 at 12:01 PM if a resident was on the substance use tracking tool, they should have an order for monitoring of substance use for 7 days on the medication administration record (MAR). Review of the tracking tool on 4/22/24 failed to reveal orders in place for Resident #572. This review also noted orders in place for Residents #583 and #584 however, failed to identify them on the Substance use Tracking tool provided to the survey team on either 4/18/24 or 4/19/24.
The DON, RDO and staff #10 who were in the conference room were also asked at that time if a policy and procedure was developed regarding this process. The RDO stated that they had not. They were further asked how staff were to know what to do. There was no response.
C. On 4/22/24 a 6-page report, listing all residents, titled Tracking and Trending of Active and Suspected residents with substance use disorders audit was provided to the survey team by the Assistant Director of Nursing, staff #5. Upon review of the audit tool errors were immediately identified and brought to the attention of the ADON, Regional Director of Operations, and DON who had remained in the conference room.
There were 9 (8, 22, 74, 76, 93, 566, 574, 583, and 584) residents randomly identified who were known and noted to have had overdoses or suspected drug use from previous review by this surveyor. All 9 were identified on the tool as having ' neither ' active or suspected substance use disorder. Specifically, Residents #566, 583 and #584 were just identified on 4/17/24, as having drug paraphernalia in their respective rooms and Residents #22, #74 and #76 were given involuntary discharge notices within the past 4 months regarding their behaviors and activity in the facility noting that the safety and health of individuals are endangered by their continued stay in the facility.
Resident #583 was also noted to have a leave of absence (LOA) order since 3/23/24, although according to the facility plan of correction, there was to be no LOA when there was actual or suspected drug use. According to the QA tracking and trending audit, Resident #583 was also noted as 'no' for LOA. The concern related to the LOA order was reviewed with the facility on 4/22/24 at 12:01 PM.
Cross reference F867
2. A review of the results from the facility's last revisit survey ending 3/8/24, revealed that an Immediate Jeopardy was identified related to unsafe smoking practices including the failure to adequately supervise residents who required supervision while smoking on 2/22/24. The facility indicated that their corrective measures would be completed by 4/8/24.
During this revisit survey on 4/18/24, an Immediate Jeopardy was identified again for unsafe smoking practices for the 3rd time related to the facility ' s failure to have a process in place to identify and consistently implement safety measures for residents while smoking and to provide supervision for residents who required supervision while smoking according to their assessments.
The facility failed to consistently implement corrective actions for this deficient practice as identified during the 11/20/23 and the 3/8/24 survey resulting in a repeat immediate jeopardy
citation related to unsafe smoking.
Cross reference F689
3. A review of the results from the facility's last recertification survey ending 11/20/23 revealed that an Immediate Jeopardy was identified related to plans of care and treatment for residents with substance use disorder that contributed to resident overdoses. The facility developed a plan to correct the immediate concerns and the immediate jeopardy was abated on 11/16/23. The facility developed a plan to correct the continued lower-level deficient practice and prevent recurrence. They indicated that the corrective measures would be completed by 1/5/24.
During a revisit survey, on 3/4/24 an Immediate Jeopardy was identified again for plans of care and treatment for residents with substance use disorder related to the facility and failure to plan care for residents with a diagnosis of Substance Use Disorder (SUD) and to monitor illicit drug use to prevent additional occurrences, relapse, and overdoses. The facility's plan to remove the immediacy was accepted on 3/4/24. The facility's plan was verified, and the immediacy was removed on 3/7/24. During this 2nd revisit survey, on 4/19/24 the survey team identified an actual harm where the facility failed to identify, monitor, and prevent additional occurrences of substance use in a resident with identified substance use disorder. The facility failed to consistently implement corrective actions for this deficient practice as identified during the 11/20/23 and again during the 3/8/24 survey.
Cross reference F 740
4. The facility was also cited during the annual survey from 11/20/23, for concerns related to a safe, clean, comfortable, and homelike environment. The facility developed a plan to correct the deficient practice and prevent recurrence. They indicated that the corrective measures would be completed by 1/5/24. These concerns and more were identified and cited during the revisit survey completed on 3/8/24. A new plan of correction was implemented with a correction date of 4/8/24. During this revisit survey, the team continued to identify concerns with the environment, including the walls, beds, and equipment in resident rooms.
Additionally, the facility failed to adequately implement pest control as per the plan of correction submitted to the Office of Health Care Quality as evident by the finding of mice and mice feces throughout the facility, including in the kitchen. The facility also failed to implement the recommendations set forth by the pest control company that they had contracted through leaving open holes throughout the facility beyond the recommended time frame in the facility resident area and the kitchen, identified during tour on 4/18/24 and throughout the survey.
In addition, upon entrance to the facility on 4/18/24, at 7:50 AM, the survey team noted in the lobby the furniture had signs posted saying ' do not sit. ' This was brought to the attention of the facility consultant, staff #1 at 8:10 AM on 4/18/24. She stated that there was a concern related to bed bugs. The survey team asked if this was reported to the Office of Health Care Quality (OHCQ). She stated at that time that she was not sure. It was determined later during the survey that it was not. The RDO reported to the survey team on 4/23/24, that he on that day reported it to the OHCQ even though the concern about reporting to OHCQ was reviewed repeatedly with the administrative team throughout the survey. Additionally, staff #1 had stated on 4/18/24, that when they found out about the bedbugs there was also an identified concern related to lice. The facility was not sure if the lice and bedbugs came from an admission or a visitor. Again, the team could not get direct information regarding these concerns or what the facility was doing to prevent further spread of these potential infestations.
Cross reference F584, F812 and F925
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on Interviews, observation, and record review, it was determined that the facility staff failed to ensure that resident rooms were free from mice. This was evident for 2 residents (#23 and #16) ...
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Based on Interviews, observation, and record review, it was determined that the facility staff failed to ensure that resident rooms were free from mice. This was evident for 2 residents (#23 and #16) of 140 residents reviewed during the recertification survey.
The findings include:
On 09/28/2023 at 2:16 PM, during an interview with Resident #23 he/she said that he/she has seen 2 mice at a time-every night and sometimes during the day.
On 09/29/2023 at 9:30 AM, a mouse was observed running across the floor in Resident #16's room. Resident #16 pointed out that the mouse will climb up cords near the head of his/her bed.
These findings were brought to the attention of the Nursing Home Administrator.
A review of service reports dated 06/01/2023 to 09/14/2023 from Orkin, the company that the facility contracts with for pest control, revealed that mice had been identified as an issue months before the start of the recertification survey.
The service reports had comments that the logbooks at the nurses' stations were checked but there were no requests made by staff. On 9/15/2023 a service report comment stated, please have nurses use logbooks in nurses' stations to report pest sightings.
A review of the logbooks verified that the logbooks in the nurses' stations were not being used by facility staff to make requests and report pest sightings.
On 10/26/2023 at 8:50 AM, an interview with Staff #2 and Staff #57 revealed that facility staff were aware there was mice problem. Staff #57 stated that she sees them go from room to room. Neither staff member had knowledge of the logbook which Orkin relied on to direct their pest management treatments on the units. Both staff members commented that if they were going to report pests they would put it in TELS, the electronic communication program.
On 10/26/2023 at 9:42 AM, an interview with Staff #7, the Maintenance Director, revealed that he only recently gained access to Orkin service reports and was unaware that Orkin was relying on facility staff to fill out the logbooks. He acknowledged there was an issue with mice and said that he has seen maybe 2 [requests] in TELS and has tried to take care of it in house. Staff #7 said that he will have to make sure facility staff are educated on using the logbooks.
Dec 2019
50 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During an interview with Resident #42 on 11/19/19 at 9:20 AM s/he shared concerns of the quality of care s/he received at nig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During an interview with Resident #42 on 11/19/19 at 9:20 AM s/he shared concerns of the quality of care s/he received at night in the facility. S/he explained that whenever the nurse used a catheter to remove urine from their bladder, it would take several attempts and usually very painful. S/he added that many of the nurses during the night shift were from an agency.
A record review for Resident #42 was conducted on 11/19/19 at 11:16 AM. The resident had diagnosis which included dysfunctional bladder that required a use of a catheter by a nurse to remove urine from the bladder every 6 hours. However, review of the October and November 2019 Treatment Administration Records (TAR) revealed several missing documentation to indicate that intermittent catherization was conducted for the resident. Further record review found no nurse/progress notes that corresponded with the missed entries to indicate that the catherization was done.
On 11/21/19 at 03:05 PM an interview was conducted with the 3rd Floor Unit Manager (UM) (Staff #5). The UM stated that Resident #42 is picky and only wants a facility nurse and not an agency nurse to insert the catheter. The UM added that this would explain why the catheterization may get overlooked since there is not much time to find a facility nurse to carry out the ordered treatment and confirmed surveyor's concerns.
The Director of Nursing was made aware of the surveyor's findings on 11/21/19.
Based on resident interview, record review, and staff interview, it was determined the facility staff failed to 1) obtain an ordered medication for a resident with Human Immunodeficiency Virus (HIV) and a history of Hepatitis C for 23 days, while the resident was being treated for a osteomyelitis (a bone infection) (#99), 2) to provide care to a venous stasis ulcer to prevent infection (#101), and 3) follow a physician's orders for skin protecting devices, and for cleaning of oxygen concentrating equipment with failure to accurately document performing the prescribed treatments and services (#20), 4) ensure that residents receive treatment and care in accordance with professional standards of practice (#32, #14). This was found to be true for 6 of 104 residents (#99, #101, #20, #32 #14, and #42) reviewed during this survey.
The facility's failure resulted in actual harm to Resident #101.
As a result of these findings, a state of immediate jeopardy was declared on 11/21/2019 at 11:36 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 11/21/2019 around 4:00 PM and the State Agency was unable to accept this plan. After several requested revision the facility submitted a plan on 11/21/19 at 8:17 PM and the removal plan was accepted at 8:27 PM. The immediate jeopardy was removed on 11/27/19 at 1:54 PM. After removal of the immediacy, the deficiency remained for potential for more than minimal harm at a scope and severity of G.
The findings include:
1) A medical record review on 11/15/19 at 11:00 AM, revealed an admission history and physical completed by Certified Registered Nurse Practitioner (CRNP) #21 on 10/23/19, which documented that Resident #99 was admitted due to a right knee prosthetic joint infection to continue Intravenous (IV) (directly in the vein) antibiotics and rehabilitation. She noted in this document that the resident was receiving Triumeq to treat HIV. In addition, review of the Physician Order Summary for October 2019, revealed the resident had an order for Triumeq dated 10/22/19 which was discontinued and reordered on 11/14/19. Review of the progress notes revealed a pharmacy review conducted on 11/5/19 documented no irregularities found.
Review of the Medication Administration Record (MAR) for October 2019, revealed the following:
- On 10/23/19, 10/24/19, and 10/25/19, the medication was documented not available by Registered Nurse (RN) #39:
- on 10/26/19, it was documented as in progress (There was no clear definition for this notation which was why staff were not to use, per DON interview on 11/20/19 at 12:43 PM) by RN #39, and
-10/27/19 - 10/31/19 it was documented by various nurses as being administered.
In addition, review of the physician's progress notes dated 10/23/19, signed by CRNP #21, 10/24/19 signed by attending physician #44, and 10/25/19 signed by CRNP #35 revealed documentation that the resident was receiving Triumeq.
Review of the MAR for November 2019, revealed the following:
-On 11/1/19, it was documented as in progress by RN #39,
-11/2/19 and 11/3/19, it was documented as administered,
-on 11/4/19, documented as in progress by RN #39,
-on 11/5/19 documented as administered,
-on 11/6/19 documented in progress by RN #39,
-11/7/19 - 11/9/19 it was documented as being administered by various nurses,
-11/10-19 - 11/12/19 it was documented as not available by RN #39 and RN #53, and
-on 11/13/19 it was documented as administered.
Review of the progress notes dated 10/22/19 - 11/13/19, revealed no documentation that the physician was made aware of the medication not being available for the resident.
During an interview with Resident #99 on 11/15/19 at 10:29 AM, the resident reported that he/she had not had their Triumeq since being admitted to the facility on [DATE] until yesterday (11/14/19). The resident reported speaking with various nurses and a supervisor regarding this issue and was told his/her insurance would not cover the medication. He/she stated I told them to call my doctor at [acute care facility] to get the medication.
On 11/20/19 at 11:17 AM, review of the facility's pharmacy receipt log for 10/2019 and 11/2019, revealed that the Triumeq was not dispensed to the facility until 11/13/19. In addition, review of facility's medication list available in the drug storage box revealed that the Triumeq was not kept on hand. This confirmed that Resident #99 went 23 days without his/her Triumeq. In addition, once the medication was restarted the resident's Infectious Disease Physician was not informed, the resident was not assessed by a nurse or a physician, and no labs were obtained to evaluate the possible effects of the discontinuation of the medication.
According to the United States Department of Health and Human Services, an individual taking Triumeq should not stop and restart the medication because the HIV strand can become resistant to the treatment causing an increase of the virus in the blood that can lead to immune suppression (meaning the immune system would not have the ability to fight infections and other complication associated with the virus). The adverse effects of HIV and immune suppression greatly increases the risk for the resident to have poor health and an early death. (https://aidsinfo.nih.gov/drugs/534/triumeq/169/professional)
During an interview with the DON on 11/20/19 at 12:43 PM, she confirmed the medication was not sent from another pharmacy. She was made aware that facility staff had been signing that it was administered during the time it was not available from the pharmacy. During the review of the documentation on the MAR, DON stated staff should not use in progress because there was no clear definition of what that meant.
An interview with RN #39 on 11/20/19 at 1:28 PM, revealed that she had called the pharmacy on 10/24/19 and was informed the Triumeq was going to cost $3,000.00 because insurance was not going to cover it. She reported that she handed the information on sticky note to the Assistant Director of Nursing (ADON) #15, whom was the acting Unit Manager, that day. She reported calling the pharmacy a second time on 11/10/19, and was informed that they had faxed a form to the facility. She stated she was aware that the house supervisor gave it to the Director of Nursing (DON) to complete. RN #39 reported that the resident also talked with the social worker that day regarding the missing medication.
An interview on 11/20/19 at 2:04 PM, with ADON #15, revealed that the pharmacy was expected to send a form to obtain permission to bill the facility for medications that were not covered by insurance. However, the form was not consistently received for each non-covered medication. At times the nurse would report the medication missing during a medication pass and at that time the pharmacy was contacted and would inform the facility it is non-covered, so there was no set process of how the facility finds out about a non-covered medication. Once the form was received it must go to the DON for approval or denial of payment. The physician should be notified as well to see if there was an alternative medication that was covered. The ADON stated she expected staff to write a progress note that the physician was made aware of the issue. The ADON reported that she was aware of the non-covered medication for Resident #99 and remembered RN #39 making her aware that the medication was going to cost $3,000 and she told RN #39 to call the pharmacy for the form and give it to the DON. Also, the ADON informed the DON during the stand-up meeting on the same day. She stated that she heard nothing more about it and did not follow up to ensure that the medication was received even though she was the acting Unit Manager for the unit in which Resident #39 resides.
The DON was interviewed on 11/20/19 at 2:29 PM, regarding the process for obtaining a non-covered medication from the pharmacy. She stated that the nurse should call the pharmacy and when the pharmacy sends the form the nurse was to give it to the Unit Manager or the DON for approval. She stated that usually the pharmacy would send a 7 day supply. She denied she was told on 10/24/19, about the issue with Resident #99's Triumeq and stated the first time she heard about it was on 11/10/19, when she was in the facility to conduct an investigation for another issue. Resident #99 informed her about the missing medication. She reported that she signed the form and sent it to the pharmacy and the medication was received a few days later. She stated that she did not investigate the issue, assess the resident, or call the physician. She stated I should have.
During an interview with Nurse Practice Educator (NPE) RN #4 on 11/21/19 at 11:26 AM, he revealed that the process for missing medication was to notify the pharmacy and the physician and document this information in the progress notes in the electronic MAR or in the progress notes field. He confirmed that he was aware that he had mistakenly signed the Triumeq as being administered to Resident #99 on 10/28/19.
An interview with LPN #6 on 11/21/19 at 2:33 PM, regarding the process staff used when a medication was not available, revealed she would document NN (nurse note) on the MAR and then call the pharmacy to find out why it was not available. When it was a non-covered medication they would send a form over for the physician to sign and then place the form in the chart for the physician. She reported she does not call the physician until she could tell them what the issue was because they don't like to be called beforehand. When asked she reported that Resident #99 had asked her about the Triumeq, but she was unsure of the date. When asked about signing the Triumeq as being given on 10/27/19 and 10/31/19, she stated she mistakenly signed it as being administered.
An interview with the Corporate DON #47 on 11/21/19 at 3:35 PM, revealed the process in the electronic medication administration record allows staff to mark each medication with a Y to show that they had prepared the medication and then go back through and press save once administered. He confirmed that it was expected that staff only click the Y once they have confirmed the medication was available for administration.
During an interview with CRNP #21 on 11/21/19 at 1:12 PM, via a phone call, revealed she was not aware the medication was not being administered to Resident #99 until asked to re-enter the order on 11/13/19. She went on to say that she expected staff to resolve medication issues with the pharmacy and not call her.
An interview with Resident #99's attending Physician #44 on 11/22/19 at 10:20 AM, via a phone call, he confirmed he was not aware the resident was not receiving the Triumeq since admission until after surveyor intervention on 11/21/19.
On 11/21/19 at 11:36 AM, the survey team conducted a meeting with the Director of Nursing, Administrator #2 and Administrator #3 regarding the concerns for discontinuation of Resident #99's medication, the multi-system breakdown that allowed this to continue for 23 days, the fact that staff marked medication as administered 50% of the time it was not available, and the lack of follow up after the issue was discovered on 11/10/19.
There were 2 related potential harms associated with the discontinuation of this medication: 1) the HIV was potentially not being suppressed which could lead to an increase in the virus and a decrease in immune function (CD4 count) putting the resident at risk for difficulty with fighting infection and other complications of the virus and 2) the potential for the virus to develop resistance to the medication, making it a less effective treatment (with same consequences).
As a result of these findings, an immediate jeopardy was declared on 11/21/2019 at 11:36 AM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 11/21/2019 around 4:00 PM and the State Agency was unable to accept this plan. After several requested revision the facility submitted a plan on 11/21/19 at 8:17 PM and the removal plan was accepted at 8:27 PM. The removal plan included the following:
A plan of correction from the facility was accepted by the State Agency on 11/21/19 at 8:27 PM, which included the following:
a.The CQS validated that resident #99's medications are available for the nursing staff to administer on 11/20/19 at approximately 1400. The Medical Director requested on 11/21/19 at approximately 1200 to speak with the residents Infectious Disease Doctor to determine if any additional treatment changes are
needed.
b. All residents currently residing in the center will have their medication orders checked against the medication carts by the CQS, Director of Nursing and Unit Managers to assure all medication is available for administration on 11/21/19.
c. All licensed nurses of the facility Manor and appointed agency nurses will have education on Medication Administration NSG305, Medication Errors NSG306, Escalation Protocol for [pharmacy name] Pharmacy and the process required to obtain medication when it is not covered by a patient's insurance plan (see attached) by
the Director of Nursing. Aspects of the education include but are not limited to OPS100 Accidents/Incidents, Medication Errors, 10.2 Medication-Related Errors, 7.0 Medication Shortages/Unavailable Medications, administering medication according to the Five Rights and the process to obtain medication when it is not covered by the resident's insurance plan. Education will be ongoing by the Director of Nursing until 100% of the licensed nurses are completed prior to their next scheduled shift. Unit Managers will be educated on initiating care plans with diagnosis of HIV on 11/21/2019 by the CQS.
d. Process Change(s): New admission medications will be requested on the next pharmacy run after being
entered into the electronic health record. The admitting nurse will verify that new admissions have their medications available during their shift. If the pharmacy has not delivered the medications during the admitting nurse's shift, the shift supervisor will be notified during shift to shift rounds to investigate why a medication is not available. If medication is not available due to non-coverage, [pharmacy name] will send a concurrent fax to the admitting unit and an electronic alert to the Director of Nursing where resident was admitted . The shift supervisors will reconcile the medication orders to medications delivered to ensure pending medications are delivered as ordered. If medication is not available, the escalation process will be followed and the Director of Nursing will be notified of the delivery discrepancies.
e. The night shift Supervisor will run the new order(s) report for all new medication orders for the prior 24 hours to verify medications are available as ordered. The new order report and its findings will be given to the Director of Nursing for review. A copy of NSG305 and the Escalation Protocol have been laminated and placed on the nursing units for ongoing reference as of 11/20/19 by the Director of Nursing.
f. Monitoring: Current medication orders and cart check audits will be completed each shift for 7 days by the
Director of Nursing and Unit Managers starting 11/21/2019. The medication order and cart check audits
will continue weekly times 4 weeks and monthly times two months by the Director of Nursing. Compliance results will be reported to the QA committee for further recommendation.
A copy of each Policy and Procedure was provided by the facility and reviewed by the survey team.
The immediate jeopardy was removed on 11/27/19 at 1:54 PM.
(Cross Reference: F580, F658, F755, F760, and F842)
4a) On 11/25/19 at 11:26 AM, Resident #32's medical record was reviewed. Review of Resident #32's November 2019 TAR (treatment administration record) revealed a 1/22/19 physician order to measure abdominal girth once a month on the 15th on day shift. There was no documentation on the TAR to indicate Resident #32's abdominal girth had been measured in November 2019.
On 11/15/19 a 2:33 PM, in a progress note, the nurse indicated that the resident's abdominal girth was not measured because the resident was in an activity. No further documentation was found in the medical record that would indicate further attempts were made to measure the resident's abdomen or that the physician had been made aware.
On 11/25/19 at 1:26 PM, the Director of Nurses (DON) was made aware of the finding. The DON stated that if the resident's abdominal girth had not been obtained, the DON would expect the nurse to pass on in report to the next shift and would expect that it would later be obtained and documented in the medical record.
4b) Review of Resident #32's November 2019 MAR (medication administration record) revealed a 6/22/19 physician order to weigh the resident every Monday on day shift, starting 6/24/19. This task was signed off as being done on 11/4/19, 11/11/19 and 11/18/19, indicating that Resident #32 had been weighed on those dates.
Review of Resident #32's weight summary in the electronic medical record (EMR) revealed Resident #32 had only one weight recorded in November 2019, on 11/19/19. Resident #32 had no weights recorded on 11/4/19, 11/11/19 or 11/18/19 which was in contradicted the documentation on resident's November 2019 TAR. Review of Resident #32's weight summary since 6/24/19 revealed the resident had a weight recorded on 7/2/19, 81/19, 8/26/19, 9/12/19, 10/25/19 and 11/19/19 which was 7 times in 22 weeks.
The facility staff failed to follow the physician's order by failing to obtain Resident #32's weight every week. The Director of Nurses was made aware of these findings on 11/26/19 at 3:20 PM
5) On 12/5/19 at 9:00 AM, a review of Resident #14's medical record revealed an 8/6/19 an Endocrinologist (doctors who specialize in glands and the hormones) consult progress note that stated the reason for the appointment was Thyroid Nodule (solid or fluid-filled lumps that form within the thyroid, a small gland located at the base the neck, just above the breast bone). The physician wrote that the resident had been found to have thyroid nodules from a prior thyroid ultrasound (imaging method to see the thyroid) and was referred for further evaluation. The physician documented that he/she did not have a copy of the thyroid ultrasound study results or actual images to review, that he/she would request a copy and indicated either physician or staff would call to discuss the next step. Continued review of the medical record failed to reveal facility staff documentation that addressed the consult or the follow-up to the consult.
Further review of Resident #14's medical record revealed a 10/21/19 CRNP (certified registered nurse practitioner) order for fine needle aspiration - upper pole of right lobe of thyroid and a 10/24/19 CRNP order for fine needle aspiration - upper pole of right lobe of thyroid. Continued review of the medical record failed to reveal evidence that Resident #14 had been scheduled for the fine needle aspiration as order by the CRNP.
On 12/4/19 at 1:26 PM, during a phone interview, Resident #14's family member stated he/she was concerned that the resident had a lump in his/her throat since May 2019 and was concerned because the facility physician was not doing anything to find out what it was.
On 12/5/19 at 10:08 AM, during an interview, Resident #14 indicated that he/she was unaware of any further work-up scheduled related to the resident's thyroid nodules. The Director of Nurses (DON) and the Corporate Nurse (Staff #71) were made aware of these findings on 12/6/19 at 2:20 PM and the DON check into the concerns related to the resident's need for follow-up.
On 12/9/19 at 9:52 AM, the Administrator was made aware of the above findings. On 12/9/19 at 10:10 AM, the Administrator confirmed that there was a delay in scheduling the resident for biopsy.
2) Interview of resident #101 on 11/18/19 revealed that s/he got a wound infection due to the facility staff not being able transport the resident to weekly wound clinic appointments. S/he indicated that the staff were to wrap her/his leg and was not being seen by a nurse.
Review of resident #101's medical record on 12/3/2019 revealed that the resident had developed a right lower leg ulcer associated with venous stasis disease and was being seen at a local wound clinic once per week beginning on 6/17/19.
The weekly wound clinic documentation was found scattered in the paper hard chart. The weekly wound consultation reports were found to be multiple pages with handwritten and typed components. At times the reports included cumulative documentation related to previous visits. Measurements of the venous leg ulcer on the right medial posterior lower leg were taken and recorded at each wound clinic visit. Review of a 8/13/19 wound consultation report revealed the venous leg ulcer was classified as a full thickness without exposed support strictures wound measuring; length (L) 9.0 cm x width (W) 2.8 cm x depth (D) 0.1 cm the report included the total area of the wound 19.782 cm and the volume at 1.979 cm. Additionally, details of the wound were provided as to amount of drainage, necrotic tissue and the appearance of the skin around the wound. The report indicated the wound to be cleansed with soap and water, apply medihoney w/ Calcium alginate dressing and protect surrounding skin with calmoseptine. The dressing change frequency indicated Do not change dressing for One Week. For edema control Unna Boot compression therapy was applied to the right lower extremity. (Unna Boot itself is a compression dressing, usually made of cotton, that has a zinc oxide paste applied uniformly to the entire bandage, which can be used for the treatment of venous stasis ulcers). The resident was to return to the clinic in 1 week. Additional instructions included Do not remove dressing unless you are ready to put back on another Unna boot! PLEASE
Resident #101 was scheduled to return to the clinic on 8/20/19 at 1 PM. Review of the wound consultation notes revealed that the resident did not return to the clinic until 9/10/19.
A nurse's note was written on 8/20/19, included wound appt rescheduled due to w/c being too wide to fit on transportation van. There was not any indication in progress notes that the resident attending was notified. At telephone order was created by the unit manager (staff #5) at 3 PM on 8/20/19 written as; Wound care: RLE [right lower extremity] clean with wound cleanser , apply Calcium Alginate to base, cover with ABD pad and wrap with Kerlix prn Mon, Wed, Fri prn Unna Boot not in place. Review of the attending physician's note dated 8/20/19 7:41 PM did not reveal any documentation related to the skin/wound status for resident #101. The attending physician had failed to provide an assessment and evaluation related to the dressing change phone order.
Clinical visit notes of 8/22/19 and 8/27/19 by a Certified Registered Nurse Practitioner (CRNP-staff#35) did not reveal any documentation related to assessment and/or evaluation of the leg ulceration. Under the plan section of both notes, revealed local dressing care of wound rt ankle per wound nurse.
Review of the skin integrity report for the RLE did not reveal weekly documentation for the progress of the condition of the wound. There was some documentation of the wound progression but with lapses of ongoing weekly documentation. The assessments and evaluations of the wound were provided by the licensed practical nurse unit manager (staff #5). Between 8/13/19 to 9/10/19 progression of the wound was documented on 8/20/19, 8/28/19, and 9/5/19. The Unna boot would have to have been removed to measure, assess, and evaluate the wound.
Review of the treatment administration record (TAR) revealed that the physician's telephone order of 8/20/19 was only performed 3 times (8/23/19, 8/25/19, 9/5/19) during the time period resident #101 was absent from the wound clinic. The staff failed to follow the prescription for dressing change. There were not any indications found in the record that the resident had refused wound clinic appointments or refusal of wound treatments during the time period s/he was not seen at the wound clinic.
The wound clinic consultation documentation of 9/10/19 was written as I have not seen [name of resident] since 8/13 at which time he had an Unna boot with Medihoney. S/he has had continued pain. [Resident #101] has tubigrip on today and it is only half on his calf (like tennis socks). All that was present was ABD (abdominal) Pad and gauze. He has maggots in the wound and on the lower leg. [name of resident] reported that he has not had a dressing change since Friday 9/6/19. The wound measured L 8.9 cm x W 3 cm x D .2, area = 20.97 and volume = 4.194 .There is Fat Layer (Subcutaneous Tissue) Exposed .there is a large amount of serosanguineous drainage noted. Foul odor after cleansing was noted. The report indicated that the wound was debrided, and subcutaneous tissue was removed. 1 specimen was taken by a tissue culture and sent to the lab. The dressing was changed to Acticoat 7 Flex and Unna boot was applied.
As of 12/3/19, the medical record was missing wound consultation reports. Upon request at 12:40 PM the facility had the wound center fax weekly consultation reports dated 9/17/19, 10/1/19, and 10/8/19.
Review of the 9/17/19 wound consultation report revealed a positive tissue [NAME] of pseudomonas and proteus mirabilis. The resident was required to be treated with IV antibiotics combat the infected wound. Resident #101 had agreed to go the emergency room for admission to the hospital. The resident was readmitted to the nursing home on 9/20/19.
Review of the care plans for resident #101 revealed a focus area initiated on 8/14/18 as Resident has actual skin breakdown related to chronic venous wound to right medial leg. The goal of this care area; The resident's wound will heal as evidenced by decrease in size, absence of erythema and drainage and presence of granulation x 90 days. The interventions to meet the goal included, 1) Observe skin condition with ADL care daily and report abnormalities. 2) Provide wound treatment as ordered. 3) skin check per policy. 4) weekly wound assessment to include measurements and description of wound status. The interventions did not include weekly wound clinic consultations. A care plan evaluation was conducted on 9/5/19 during the 4-week absence from the wound clinic. The unit manager (staff #5) wrote Resident seen by wound center for Unna boot weekly, will continue plan of care. The evaluation did not reflect the wound status. The wound was not decreasing in size and the Unna boot was not being utilized and by 9/5/19 had missed 3 weekly wound clinic appointments without indication of physician oversight.
At 12:40 PM on 12/3/19 the unit manager was asked questions related to the telephone order that she had written on 8/20/19. She indicated that the dressing should have been changed on Monday, Wednesday, and Friday when the Unna boot was not in place. She revealed that the resident was not seen by the in house wound consultant nurse as the resident was to go to the local wound clinic weekly.
Resident #101 was interviewed on 12/3/19 at 2:53 PM s/he acknowledged going to the wound clinic and the wound is close to being completely healed. When asked about the maggots being found in the wound s/he blamed the facility for not providing transportation or not having an escort to go along with her/him. S/he indicated that the facility would not have the supplies to do the treatment and/or staff would pass the treatment off to be performed by a different shift.
The unit manager was interviewed on 12/4/19 at 11:14 AM, She was asked about identification of maggots being found in the wound. She indicated that there were not maggots when she measured resident #101's wound. She acknowledged that she did not do the dressing change when she measured the wound. She had indicated that resident #101 was seen by the in-house wound consultant on 12/4/19.
A phone interview was conducted with the certified registered nurse practitioner wound consultant (staff #20) on 12/4/19 at 12:45 PM. She when a resident is seen at a wound clinic, she does not see those residents. She indicated that it would not be ethical for her to review a resident that is being seen by another consultant. She acknowledged visiting the resident on 12/4/19 as the resident is reportedly to be discharged from the local wound clinic.
At 1:05 PM the medical director was informed of the facility's inability to get the resident to weekly wound clinics with the lack of documentation from the resident's attending or CRNPs related to wound assessments/evaluations. The medical director was informed of the facility's inactions and the discovery of maggots in the wound and ensuing wound infection requiring hospitalization of the resident.
Ongoing review of resident #101's medical record had revealed that CRNP (staff #21) had made visits to the resident on 8/23/19 and 8/29/19. Under the physical exam part of the visit notes indicated identical statements written as Right leg wound 7 x 4 x 0.2 cm. 100% necrotic. Periwound is intact. Mod drainage. Slight odor. At 2:20 pm on 12/4/19 an interview was conducted with CRNP (staff #21). She was shown printed copies of the 8/23 and 8/29/19 note. She indicated that she did not provide those wound measurements. She acknowledged that the facility utilizes templated notes and the measurements and observation data on the visitation notes was old data. She indicated that she had not assessed and/or evaluated the residents wound.
At 3:45 PM on 12/4/19 the director of nursing was asked if the Quality assurance and performance improvement committee (QAPI) did any interventions when the resident was found to have had maggots in the wound on 9/10/19. She acknowledged that she was aware of this for the first time upon surveyor request for wound consultation notes. The QAPI committee was not aware that a resident was found to have had maggots [TRUNCATED]
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on record review, staff and resident interview it was determined that the facility staff failed to ensure that residents were free from abuse and neglect. This was evident for 8 of 33 residents ...
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Based on record review, staff and resident interview it was determined that the facility staff failed to ensure that residents were free from abuse and neglect. This was evident for 8 of 33 residents (#60, #116, #141, #142, #143, #133, #140, #63) reviewed for abuse and neglect. As a result of this failure, actual harm was identified for Resident #60.
The findings include:
1) Review of Resident #60's medical record revealed the resident was admitted to the facility in June 1998 with a diagnosis that included schizophrenia. Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. Resident #60's medical record revealed 2 certifications of incapacity to make informed decisions dated 8/4/11 and 8/31/11. An assessment was completed by the facility staff on 10/4/19. The facility staff documented on 10/4/19 a Brief Interview for Mental Status (BIMS) Summary Score of 5/15. A score of 5 indicates severe cognitive impairment.
Review of Resident #116's medical record revealed the Resident was admitted to the facility in November 2018 from the hospital for rehabilitation. Resident #116's medical record revealed that on 11/30/18 the physician certified the resident had adequate decision-making capacity. An assessment was completed by the facility staff on 11/1/19. The facility staff documented on 11/1/19 a BIMS Summary Score of 14/15. A score of 14 indicates the resident is cognitively intact.
Review of a facility reported incident (MD00148600) revealed the facility submitted a report on 12/4/19 to OHCQ (Office of Health Care Quality) indicating that on 12/4/19 Resident #116 was observed by the Recreation Director with his/her hand in Resident #60's pants. The Recreation Director reported the incident to the Administrator.
Review of the Resident #116's care plans revealed a care plan initiated on 3/22/19 for: Resident has a tendency to exhibit sexually inappropriate behavior related to tendency to make sexually suggestive remarks and inappropriate touching female residents.
During interview with the Director of Nursing (DON) on 12/10/19 at 1:23 PM, the DON stated the care plan for sexually inappropriate behaviors was initiated for an incident that occurred on 3/21/19 where Resident #271 accused Resident #116 of touching the him/her on the buttocks on the elevator. The DON stated the incident could not be substantiated but a care plan was put in place to monitor Resident #116's behaviors. The DON stated there had been no other incidents since 3/21/19 of Resident #116 inappropriately touching other residents until 12/4/19.
During interview with the Administrator (Staff#3) on 12/10/19 at 1:40 PM, she stated that on 12/4/19 Resident #116 was immediately placed on a 1 to 1 supervision and will remain on 1 to 1 supervision until discharge. She also stated Resident #116 was issued an involuntary discharge notice on 12/4/19 and the resident agreed to discharge. The Administrator (Staff #3) also stated the Resident #116 was seen by a psychiatrist after the incident.
During interview with the Recreation Director on 12/10/19 at 1:48 PM, she stated on 12/4/19, she was standing inside the dining room watching residents come to church service, which was held in the dining room. Resident #60 was sitting in wheelchair outside the dining room. Resident #116 exited the dining room in a wheelchair after smoking on the patio, which is connected to the dining room. She saw Resident #116 stopped next to Resident #60 in the hallway outside the dining room. She then stated she saw Resident #116's hand under Resident #60's smoking apron and moving in Resident #60's lower private area. The Recreation Director stated she called Dietary Aide #2 over. She stated as she got closer, she saw Resident #116 remove his/her hand from Resident #60's pants and placed it on the Resident #60's shoulder. The Recreation Director then stated Resident #116 wheeled towards the elevator and she followed him/her. She asked Resident #116 what just happened, the Resident stated, you know what I was doing, I was making him/her feel good. I was playing with it. The Recreation Director stated she got the Administrator immediately. The Recreation Director was asked if she has ever seen Resident #116 inappropriately touching other residents before, she stated, no. She stated she has worked at the facility since October 2018.
The surveyor attempted to interview Resident #60 on 12/10/19 at 2:49 PM. The surveyor asked if anyone had touched him/her inappropriately. The resident stated no and just put his/her head down. The resident would not answer any further questions.
During interview with Dietary Aide #2 on 12/11/19 at 8:41 AM, she stated the Recreation Director was inside the dining room by the doors decorating and she was by the kitchen area inside the dining room. She stated the Recreation Director called her over to where she was standing. Dietary Aide #2 stated when she went over to the dining room entrance, Resident #116 and Resident #60 were both in wheelchairs sitting next to each other and Resident #116 had his/her arm around Resident #60 asking if the Resident was fine. She stated Resident #116 then rolled away.
During interview with Resident #116 on 12/11/19 at 8:30 AM about the incident, the resident stated that the incident was just misinformation and he/she never touched Resident #60 inappropriately. When asked if he/she touched Resident #60 at all, Resident #116 stated I just gave the Resident a bump on the elbow and asked how he/she was doing. Resident #116 stated the person that reported the incident was just hating on him/her and jealous.
Interview with the Administrator (Staff #3) on 12/11/19 at 11:43 AM, confirmed the facility substantiated abuse by Resident #116 against Resident #60 on 12/4/19.
2) Review of facility reported incident MD00147651 on 11/26/19 revealed on 11/10/19 Geriatric Nursing Assistant (GNA) #32 closed Resident #116's door to his/her room without consent, had a verbal altercation and then pushed the resident to the floor. The facility did an investigation and substantiated that the abuse occurred. The facility terminated GNA #32 on 11/13/19 and reported the abuse to the Board of Nursing. The Director of Nursing (DON) was advised that the facility would be cited for abuse on 11/27/19 at 10:20 AM. The DON stated, yeah, I can't believe she called me right away on the phone to tell me her side of what happened.
3) Review of facility reported incident MD00130510 on 11/26/19 revealed that Resident #141 reported on 8/20/18 that on 8/18/18 GNA #61 told the resident, [expletive] you and gave the resident the middle finger. The resident sustained a fall on the patio and the resident reported that GNA #61 stated, if they would stop self-medicating they would not fall. There was a verbal altercation between GNA #61 and Resident #141.
Verbal abuse was substantiated by the facility and GNA #61 was reported to the Board of Nursing.
4) Review of facility reported incident MD00130294 on 11/26/19 revealed that Resident #142 was verbally abused by staff. The employee admitted to using a profane term when talking to the resident. The employee was terminated after staff and resident interviews and was reported to the Board of Nursing.
5) Review of facility reported incident MD00131205 on 12/2/19 revealed Resident #143, a transgender resident, reported that he/she was on the elevator with another resident and Staff #62, a dietary aide. Resident #143 reported that Staff #62 referred to Resident #143 as a him or her or whatever. The facility reported as emotional abuse and terminated Staff #62.
On 12/4/19 at 10:40 AM the DON stated that sensitivity training was done, however she could not find the sign-in sheets as to who was trained.
6) Review of facility reported incident MD00144596 on 12/3/19 revealed on 8/26/19, Staff #58, a unit secretary, was verbally abusive to Resident #133 as Staff #58 was speaking to someone in front of the elevator and stated, I don't want to go out with this (expletive) crackhead. The facility validated the verbal abuse allegation through the interview process and Staff #58 was terminated. The resident was no longer in the facility, therefore was not available for interview.
7) Review of facility reported incident MD00144048 on 12/6/19 revealed Resident #140 reported to the social worker on 8/11/19, that the 11-7 GNA, (GNA #59) from the previous night neglected to provide him/her with incontinence care. The resident reported that around 6 AM he/she turned on the call light and a female answered the call light. The resident reported that GNA #59 was told that Resident #140 had an accident and needed to be changed. The resident reported that GNA #59 came in, turned off the call light, found out what the resident needed and left saying, You alright, go back to sleep. The resident immediately turned the call light back on and GNA #60 answered the call light and provided incontinence care.
Neglect was substantiated by the facility and GNA #59 was reported to the Board of Nursing.
8) Review of facility reported incident MD00148638 on 12/10/19 revealed that on 11/22/19 Resident #63 reported that GNA #57 grabbed the resident's left arm, in the deltoid area, and pushed the resident back from a sitting position back to the mattress.
On 12/10/19 at 12:05 PM Resident #63 was interviewed and stated, I had an incident a couple of weeks ago with a GNA. The resident, who was alert and oriented, stated, the GNA was rough with me and grabbed my arm and pushed me down on the bed. The resident stated, I was trying to help her by pulling up the top of the sheet and blanket. She grabbed the top of my left arm and pushed me down. The resident demonstrated being pushed back on the bed. The surveyor asked if he/she was hurt and the resident stated, It hurt my bone. Luckily I didn't have any bruising. The surveyor asked if the resident was fearful of the GNA and the response was, Yes, I kept my mouth shut. I didn't know what she was going to do. She walked over and closed the curtain, so I didn't say anymore. When asked if she reported it to anyone she said, I told the nurse what happened. I don't cause anyone any trouble. I know the girls are overworked.
On 12/10/19 at 12:10 PM an interview was conducted with the Nursing Home Administrator (NHA) Staff #3 who did the investigation. She stated that she had to substantiate the abuse because the agency GNA would not call her back. The NHA stated that the incident was reported to the Board of Nursing.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) A medical record review for Resident #114 on [DATE], revealed the resident was admitted on [DATE] following a surgical interv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) A medical record review for Resident #114 on [DATE], revealed the resident was admitted on [DATE] following a surgical intervention for an abdominal abscess. The resident had the following diagnoses: End Stage Renal Disease (ESRD) with dependence on hemodialysis (a process to clean the blood when the kidneys are not able), Diabetes Type II, Thyroid Disease, and a weak left leg affecting mobility. These diagnoses placed the resident at a higher risk for skin breakdown.
Review of the physicians' order summary revealed wound care orders. There was an ordered dated [DATE], written by CRNP #20 stated, Sacral wound, left inferior buttocks, left superior buttock wounds. Cleanse with cleanser. Apply hydrogel to open areas. Cover with optifoam gentle every day shift. This order did not state which cleanser to use. Also, this order was for several areas and one area (left superior buttocks) was noted to have been healed on [DATE] and this order was not discontinued until [DATE].
Review of the physician progress notes revealed that Resident #114's attending physician visited in [DATE] on the 22nd, 23rd, 25th, 28th, 31st and in [DATE] on the 4th, 6th, 11th, 14th, 18th, and 21st. However, there was no documentation regarding the resident's wounds.
A comparison review of the resident's admission skin sheet dated [DATE] and the Skin Integrity Reports initiated on admission revealed that the following was noted that she had skin breakdown as followed: right buttocks 3x1.5, heel 3 x 3 101 cm surgical wound left upper quadrant and right upper quadrant 3 x 2 listed for pressure areas, however the care plan portion was not completed to indicate interventions to prevent further skin breakdown.
Further review revealed that Skin Integrity Reports (these reports allow an assessment of staging, size, wound edges, wound bed, surrounding tissue, drainage, and odor for 10 weeks) were initiated for the following areas: sacrum (area between buttocks and lower back) that measured 6 cm x 4 cm, middle abdomen surgical site measuring 101 cm, right upper abdomen 3 x 2 cm, right MASD (moisture acquired skin damage) greater trochanter (hip). There was an additional Skin Integrity Sheets that was not dated and initiated before [DATE] for the left inferior (lower) buttocks measuring 3 x 3. There were discrepancies between the 2 forms of documentation, which made it uncertain which wounds the resident had at the time of admission.
Subsequent documentation regarding wounds on the Skin integrity Sheets revealed the wounds were assessed on [DATE], [DATE], [DATE], with new pressure areas found on right heel and right hip on [DATE]. All of the assessment fields were not completed and some were not initialed by the nurse completing the assessment. Staff failed to complete the full assessment of the wounds on a weekly basis.
An observation was made on [DATE], of Resident #114's wound care performed by Certified Nurse Practitioner (CRNP) #20 and the Assistant Director of Nursing (ADON). The CRNP #20 asked the resident how he/she was doing and informed him/her of the procedures. The CRNP #20 measured the wounds while the ADON documented on the Skin Integrity Sheets. The CRNP used the same ruler to measure the wounds starting with the sacral wound, left buttocks, then right greater trochanter, and right lower hip wound. Surveyor noted there were two red areas between the right greater trochanter and right lower hip wound which were not assessed during the observation. The CRNP reported that the resident's santyl ran out and she was not sure when that happened and changed the wound dressings. Santyl is used to breakdown and remove dead tissue from a wound. She exchanged it for Medhoney which was an aid to the debridement of the wound. The ADON wrote down all the information provided by the CRNP regarding each wound and assisted with the dressings. She had placed gloves in her scrub shirt pockets and was pulling them out to use them. During the observation it was noted that the CRNP #20 frequently referred back to the documentation on the Skin Integrity Sheets, which as noted above were incomplete. The measurements and assessments of the wounds were used to determine if the resident's wound were improving or declining.
A subsequent observation was made on [DATE] and 1:29 PM, with the Director of Nursing (DON) and Registered Nurse (RN) #39 of the two areas the surveyor noted during wound rounds between the right greater trochanter and the right lower hip wound. The DON removed the hip dressing as it covered both wounds. She proceeded to assess the wounds and found they were non-blanchable (means when pressed on it does not turn white then red again) reddened areas. She stated she would have expected them to be documented on a Skin Integrity Sheet to watch and make sure they did not progress. RN #39 proceeded to redress the wound. During a conversation after the observation the DON stated she had a conversation with the corporate wound nurse regarding the CRNP #20 wound care and some concerns about her assessments and orders. She was aware that the orders were grouping several wounds together. She was made aware of the concern with using the same measuring tools for each wound and staff using gloves from their pockets during the wound care.
A subsequent review of the wound orders after the observation on [DATE], conducted on [DATE] at 2:50 PM, revealed that each wound has a separate order written.
The DON was made aware of the concerns on [DATE] at 1:28 PM.
Cross Reference: F711, F725, F692, F842
5) The facility staff failed to do weekly skin assessment and perform dressing changes as ordered for pressure ulcers for a resident.
Review of Resident #17's medical record revealed the Resident was admitted to the facility in [DATE]. Further review of the Resident's medical record revealed the Resident was discharged from the hospital back to the facility on [DATE] with the following pressure ulcers: sacrum, right lower leg, left lower leg and left heel.
Review of the Resident #17's weekly skin assessment revealed the facility staff failed to perform a weekly skin assessments on [DATE], [DATE] and [DATE].
The standard of practice for the care of pressure ulcers is for the facility staff to conduct weekly assessments and document findings that include the location, measurement, stage and characteristics of a pressure ulcer. This information provides facility staff with information to determine whether the pressure ulcer is healing or worsening at future assessments and to evaluate which treatment plan would be most effective to heal the ulcer.
Review of the Resident #17's Treatment Administration Records for October and [DATE] revealed the facility staff failed to perform dressing changes as ordered on:
1. Left lower leg and heel on [DATE], [DATE] and [DATE]
2. Right lower leg on [DATE] and [DATE]
3. Sacrum on [DATE] and [DATE]
Interview with the Director of Nursing on [DATE] at 7:56 AM confirmed the surveyor's findings.
4) Review of Resident #36's medical record on [DATE] revealed the resident was admitted on [DATE] from an acute care facility. The discharge summary from the hospital on [DATE] documented that the resident had multiple wounds on the back.
A skin integrity sheet was started on [DATE] for a rash on the mid back, abdominal folds and back of knee. A second skin sheet was started for a skin tear on the mid back and a third skin sheet was for an abscess on the lower back. There was no buttock skin sheet. The abscess notes of [DATE] documented a stage 2 on the sacrum, a lower back wound and notes documented that the wounds were improving. There was no further documentation on skin sheets which tracked the progress of the skin integrity. There was no skin sheet for the stage 2 on the sacrum.
A care plan, resident at risk for skin breakdown related to surgical/ulcer and has actual skin breakdown type: surgical, ulcer, rash had the goal the resident's wound/skin impairment will heal as evidenced by decrease in size, absence of erythema and drainage and or presence of granulation. An intervention on the care plan, weekly wound assessment to include measurements and description of wound status was created on [DATE]. The care plan was not followed as weekly wound assessments to include measurements and description of the wounds was not done.
An interview was conducted with LPN #5 on [DATE] at 12:02 PM who stated that when the resident first came in the resident had antibiotics due to a large wound on the back with MRSA (Methicillin-resistant Staphylococcus aureus) which is a bacterium responsible for several difficult-to-treat infections in humans. LPN #5 stated that the resident had skin folds with fungal dryness which would improve but had to deal with the constant moisture in the folds. LPN #5 stated, the last time I visualized his/her wounds was on the day he/she went out to the hospital, which was on [DATE]. He/she had some purulent drainage and the wound looked a little bigger.
An interview was conducted with GNA #34 on [DATE] at 12:11 PM who stated, his/her bottom was red with 1 area open.
An interview was conducted with CRNP #35 on [DATE] at 12:15 PM who stated, I saw his/her wounds. He/she had candidiasis in the groin area. CRNP #35 stated that the resident had issues with wanting care and that he/she would refuse care. The resident was followed by the wound care CRNP, CRNP #20, and was seen on [DATE], [DATE], [DATE], [DATE] and [DATE]. The only measurements of the wounds were done on the CRNP assessments. The CRNP did not see the resident weekly, therefore skin integrity was not being monitored and documented during the time period when the wound CRNP did not see the wounds.
Discussed with the Director of Nursing on [DATE] at 3:30 PM who confirmed the lack of skin monitoring.
Based on medical record review, interviews and observations it was determined that the facility failed to provide care consistent with professional standards of practice to prevent the development of pressure ulcers and to provide care to promote healing of identified ulcers as evidenced by: 1a) the failure to ensure a newly identified pressure ulcer was assessed by a health care practitioner for more than two weeks (Resident #110); 1b) failure to re-evaluate the nutritional needs of a resident with a pressure ulcer when a protein supplement order expired (Resident #110) 1c) failure to ensure staff provided g-tube supplemental feedings as ordered (Resident #110) and 1d) failure to ensure nursing staff provided dressing changes as ordered (Resident #110); 2) failure to ensure primary care provider or wound nurse practitioner were made aware of signs of a wound infection (Resident #82). This was found to be evident for 6 out of 10 residents (Resident #110, #82, #101, #36, #17, #114) reviewed for pressure ulcers during the survey.
This deficient practice resulted in actual harm to Resident #110.
The findings include:
1. A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed).
On [DATE] review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive, chronic kidney disease, high blood pressure, diabetes and lung disease. The resident has had a g-tube since 2018 although the resident does consume meals by mouth. Review of the [DATE] minimum data set assessment revealed the resident requires extensive assist from staff for bed mobility and eating. The resident's weight in [DATE] ranged from 124.8 - 130.4 lbs.
1a) Review of the [DATE] Care Plan Evaluation note revealed resident's skin was intact at that time. Review of the physician orders revealed an order in effect from [DATE] through [DATE] to cleanse left open inner ankle blister with NSS [normal saline], pat dry, apply bacitracin ointment and cover with border gauze every day shift. Review of the [DATE] Care Plan Evaluation note revealed the following: Resident noted with a closed blister to inner ankle. Treatment in place. Will have wound nurse eval on next visit. Review of the corresponding Skin Integrity Report revealed documentation of an in house acquired pressure ulcer to the left medial [inner] ankle.
The Skin Integrity Report has areas to document the progression of a skin wound over a 10 week period.
The area of this Skin Integrity Report for the initial wound date failed to reveal a legible date. The initial wound documentation revealed the wound was 2.1 by 1.6 cm. The second week's documentation was dated [DATE] and revealed the wound was documented as a stage 2 pressure ulcer measuring 2.1 x 1.0 cm.
According to state regulations staff shall document the progression of a skin condition weekly until the condition is healed. Further review of the Skin Integrity Report for the ankle wound revealed documentation from 8/17 thru 10/30. No weekly documentation was found for the weeks of [DATE]; [DATE] or [DATE].
The Director of Nursing (DON) reported on [DATE] at 1:12 PM that the wound nurse typically comes every Wednesday but some Wednesdays she does not. She went on to report that the wound nurse does not see every resident [with wounds] every week. When asked how it is determined who the wound nurse sees the DON reported that there are skin sheets [Skin Integrity Reports] in the book and the wound nurse sees these sheets when she comes in. The DON also reported that the unit nurse managers are aware to let the wound nurse know if someone needs to be seen.
Further review of the medical record failed to reveal documentation that the wound nurse assessed the resident's ankle wound when she was scheduled to be in the building on Wednesday [DATE]th or Wednesday [DATE]. Review of the wound nurse progress note for a [DATE] date of service revealed the left medial ankle wound was 4.1 x 3.2 cm x UTD [unable to determine depth] and was currently unstageable with 95% of the wound with necrotic tissue. The order for the treatment to the wound was changed on [DATE] to cleanse left medial ankle with wound cleanser, apply medihoney to base and cover with foam dressing every day and as needed.
Further review of the medical record failed to reveal documentation that the wound nurse re-assessed the resident's ankle wound until more than a month later on [DATE] at which time the wound was assessed to be 1.9 cm X 3.1 cm x 0.1 cm and a stage 4.
On [DATE] nurse #40 completed a change in condition note that revealed the presence of skin wound on the resident's backside. The note revealed the primary care nurse practitioner was made aware and wanted the wound nurse to evaluate the patient. The corresponding Skin Integrity Report revealed an in house acquired pressure ulcer, stage 2 measuring 1 cm in length with a width of 0.
Further review of the Skin Integrity Report for the sacral pressure ulcer revealed documentation from [DATE] thru [DATE]. This is an 11 week period but there is only documentation for 9 weeks. No weekly documentation was found for the week of [DATE]th. There is only one assessment documented between 10/24 and 11/13 but the date is not legible. There is a section at the bottom of this form for the nurse's signature/initials and an area for initials when the weekly assessment is completed. Of the nine assessments completed, only one has a corresponding nurse signature. This was for licensed practical nurse #40 who completed the initial assessment only.
On [DATE] at 10:21 AM the DON reported that the nurse assigned to the resident is responsible for assessing and documenting newly identified pressure ulcers. She went on to report that if the assigned nurse is an LPN the LPN would let the supervisor know to come look at the wound and stated that there is always an RN in the building. DON also reported that the unit nurse managers are expected to measure and document the progression of a pressure ulcer when the wound nurse is not completing the wound assessment. Surveyor reviewed the concern that the initial assessment of the sacral wound was completed by an LPN #40.
On [DATE] surveyor requested from the DON identification of the nurses who initialed the assessments for the sacral wound Skin Integrity Report on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 11/(illegible), and [DATE]. When the DON provided the requested information a new copy of this report was provided that had documentation for [DATE] added in the margin. No documentation was found, or provided, to indicate a wound assessment was completed for the week of [DATE]. A signature for registered nurse #8 was found to have been added to this Skin Integrity Report that corresponded to the assessments completed on [DATE] and [DATE]. The DON failed to provide information regarding the identification of the nurses who completed the [DATE], [DATE] and 11/ (illegible date) assessments.
Further review of the medical record revealed the wound nurse practitioner gave an order for sacral wound care on [DATE]. Review of the care plan revealed it was updated on [DATE] to include the presence of the sacral wound and resident to be seen on wound rounds was added to the interventions.
On [DATE] at 8:58 AM the wound NP #20 reported that she sees all of the residents with wounds on the rehab unit each week and alternates wound rounds on the two long term care units, thus seeing the long term care residents with wounds every other week. She went on to report that the expectation is that the unit nurse manager conduct the wound rounds on the alternate weeks and alert her is a wound is not stable. If there is a new wound the staff usually asks the wound NP to see the wound but she clarified that she typically does not assess stage 1 or stage 2 wounds. She confirmed that even if there is a new stage 2 wound she would not assess it until it is a stage 3. She went on to report that she will see anything they ask me to see, sometimes the staging isn't correct.
Further review of the medical record failed to reveal documentation that the wound nurse assessed the resident's new pressure ulcer when she was scheduled to be in the facility for wound rounds on Wednesday [DATE] or 18. On [DATE] at 9:28 AM the wound NP #20 reported she was in the facility on [DATE] and 18 but was not sure why she did not see the resident.
Review of the primary care physician progress note for [DATE] date of service failed to reveal documentation regarding the presence of either the ankle or the sacral wound.
Further review of the medical record failed to reveal documentation that a physician or a nurse practitioner assessed the residents sacral wound from the time it was first documented on 9/5 thru [DATE].
Further review of the medical record revealed the wound nurse practitioner (NP) #20 assessed the resident on [DATE]. Review of the progress note for this visit revealed the left ankle wound as being 1.9 x 3.1 x 0.1 cm stage 4 and the sacral wound 3 x 4 x 0.1 cm with heavy drainage and a stage 3.
Further review of the medical record revealed that on [DATE] the resident was seen by the primary care physician. This note revealed documentation under Physical Exam Skin section that was identical to the assessment completed by the wound NP #20 in her [DATE] note. There is no notation that these measurements were from the [DATE] NP note. Interview with the primary care physician (PCP) #44 on [DATE] at 10:11 AM revealed that he was aware the resident currently had sacral and ankle ulcers. Confirmed that he does not assess pressure ulcers every time he sees the resident and went on to state that they have a wound nurse that comes once a week. The PCP went on to confirm that he did not measure the resident's wounds as indicated in the [DATE] note, stating that he goes with the measurements provided by the wound nurse.
On [DATE] the wound NP #20 saw the resident. Review of the note from this visit revealed the left ankle wound with a bit of decline and was 1.3 x 0.6 x 0.1 cm stage 4. The Physical Exam section of the note documented the sacral wound: 4 x 3.5 x 0.1 cm. 100% slough, 0% granulation. heavy drainage. stage 3, however in the Diagnosis and Assessment section the pressure ulcer of the sacral region was documented as a stage 4 and included Sacral wound- Decline. Too moist. The documentation on the Skin Integrity Report for [DATE] documented the stage as: unstageable.
1b) Review of the medical record revealed that from [DATE] until [DATE] the resident's g-tube feeding order was for 80 cc Jevity 1.5 after meals.
On [DATE] the resident's weight was 128.9 lbs.
On [DATE] there was an order for Protein Liquid two times a day for wounds until [DATE] give 30 cc Proheal via mouth with breakfast and lunch. Review of the Medication Administration Record (MAR) revealed documentation that the supplement was administered as ordered from 9/9 thru [DATE].
Review of the medical record revealed the resident was seen by the Registered Dietician (RD #17) on [DATE]. Review of the note from this visit revealed average oral intake was 50 - 75% with assistance by staff. The note also documented the presence of pressure ulcers: Sacrum stage 1 and left ankle unstageable; and that the resident has increased nutrition needs for PU [pressure ulcer] healing. The note revealed the resident was currently receiving the Proheal 30 ml two times a day and Jevity 1.5 [1.5 calories per ml] 80 ml via the feeding tube after meals three times a day. The RD's recommendations included to continue regular liberalized puree diet, assist with PO intake; continue tube feeding as ordered; and continue Proheal 30 ml two times a day for wound healing.
Further review of the medical record failed to reveal an RD re-assessment on [DATE] when the order for the protein supplement stopped.
During an interview on [DATE] at 2:23 PM with RD #17, she reported she did not think she wrote the protein supplement order and did not recall if she was aware that it was only for 30 days. The RD went on to report that the protein supplement did not add that many calories [in regard to weight loss] but confirmed it was a significant amount of protein.
The protein supplement provided an additional 30 gms of protein and 200 calories to the resident's diet per day.
On [DATE] review of the medical record revealed a physician order, originally written [DATE], for 100% supervision with all PO intake with meals. Further review of the GNA documentation revealed the coding for documentation for Eating -Self performance as follows: 0- Independent - no help or staff oversight at any time; 1 - Supervision- Oversight, encouragement or cueing; 2 - Limited Assistance - Resident highly involved in activity, staff provided guided maneuvering of limbs or other non-weight-bearing assistance; 3-Extensive Assistance - Resident involved in activity, staff provide weight -bearing support or 4 - Total Dependence - Full staff performance.
Further review of the resident's care plan revealed an intervention of assist with PO [by mouth] intake was added on [DATE]. Review of the Geriatric Nursing Assistant (GNA) documentation for meals revealed staff documented set up help but that the resident wasindependent -no help or staff oversight at any time with eating for 18 out of 36 meals from [DATE] thru the 30th. Staff documented the resident as being totally dependant for eating for the other half of the meals provided during this time period. Review of the GNA documentation for assistance provided with meals for October and November also documented the resident as independent for more than half the meals provided to the resident. On [DATE] at 4:07 PM surveyor reviewed the concern with the DON that GNA documentation from past 30 days revealed staff documenting resident as independent with meals on many occasions.
Further review of the [DATE] wound NP #20 note revealed: on tube feeding and supplements. Further review of the medical record failed to reveal any documentation that the resident received, or had current orders for, a nutritional supplement after the protein supplement order expired on [DATE]. From 10/13 thru 10/24 the resident did not receive any protein supplement or increase in g-tube feeding.
On [DATE] the resident's weight was recorded as 114 lbs indicating a significant weight loss. On [DATE] the resident's weight was 114.4 lbs. On [DATE] RD #17 completed a weight change progress note which addresses the significant weight loss of 11.2 % x 30 day; 9.4% loss in 90 days and 14.6% loss over 180 days. PO [by mouth] intake varies at meals, needs assistance , on average 50% intake notes Resident has increased nutrition needs for wound healing. The RD recommended increasing the tube feeding to 1 can (237 ml) Jevity 1.5 after each meal. A corresponding order, dated [DATE], for the 1 can of Jevity after meals was found in the medical record. The RD also recommended weekly weights times 4 weeks. On [DATE] surveyor reviewed the concern with the RD #17 that the supplement ended and was not re-evaluated, the resident's wound worsened and the resident experienced a significant weight loss.
On [DATE] the wound NP #20 assessed the resident's wounds. The note for this visit revealed left ankle wound was 1 x 1.2 x 0.1 x 0.1 cm and bit of decline. The Sacral wound was 4 x 2.5 x 1.0 cm with heavy drainage Stage 4 and decline.
On [DATE] the resident's weight was recorded as 132.6 lbs. This represents a gain of more than 15 lbs in less than 2 weeks. No documentation of a re-weight was found in the medical record. On [DATE] at 8:19 AM RD #17 reported that staff is suppose to get a re-weight if greater than 5 lb change either way. The next recorded weight was on [DATE] and was 113.4 lbs.
1c) On [DATE] at 9:48 AM surveyor observed an unopened container of Jevity on the resident's overbed table. On [DATE] at 11:04 AM the unit nurse manager #8 observed the Jevity container with the surveyor. The nurse manager reported it had been opened but was not empty at this time and proceeded to throw out the container.
On [DATE] at approximately 2:45 PM review of the medical record revealed documentation that nurse #40 had administered the Jevity on [DATE] at 10:00 AM.
On [DATE] at 3:04 PM nurse #40, who had been assigned to care for the resident during the day shift, reported the resident was a feeder [a resident in need of assistance with eating]. When surveyor asked nurse #40 if the resident received all nutrition by mouth, the nurse reported: yes. The nurse went on to report if the resident doesn't eat up to 50% he would give the resident a bolus [can of feeding via g-tube]. He confirmed that he had not administered any Jevity today, stating the resident has been going over [the 50%] for eating.
When surveyor reviewed with Nurse #40 that the documentation revealed that the resident is to receive one can of Jevity after meals and that he had documented the administration of the Jevity the nurse reported that he would have to strike it because the resident ate and he did not give the Jevity. He confirmed that he did not administer the Jevity in the morning either. On [DATE] at 3:09 PM the nurse was observed reviewing the orders in the electronic health record and stated looks like they changed the order, how they had [him/her] was if [he/she] eats over a certain amount we don't give the bolus, when I work with [the resident] that is how it's been. The nurse went on to report that he is employed by an agency and usually works on this unit or the rehab unit.
On [DATE] at 3:28 PM surveyor reviewed the concern with the DON regarding Nurse #40's documentation that the Jevity had been administered despite his report that the resident does not receive the Jevity unless the resident eats less than 50% of meals and confirmation that he had not administered the Jevity today.
Further review of the MAR and the nursing notes revealed that Nurse #40 documented that the [DATE] Jevity was administered at 10:00 AM. The dose due at 2:00 PM was documented as being held [not given]. The corresponding nursing note with an effective date of [DATE] at 3:09 PM revealed a notation that the resident eat over 50% of [his/her] meal. Further review of the medical record revealed that from [DATE] until changed on [DATE] the resident's g-tube feeding orders were: after meals give 1 can Jevity bolus if PO [by mouth] intake is less than 50%.
1d) On [DATE] at 11:37 AM surveyor began the observation of Nurse #13 complete a dressing change for Resident #110's left ankle and sacral pressure ulcers. At 11:45 AM the nurse reported he just re-checked the orders.
During observation of the sacral wound dressing the nurse cleaned the wound with wound cleanser, applied skin prep to the periwound area, applied metronidazole powder to the wound base and packed the wound with gauze moistened with the wound cleanser, and then covered the wound. On [DATE] review of the physician orders for the sacral wound, in effect since [DATE], revealed they included: Calazine to wound edges. The nurse had not used Calazine during the sacral wound dressing change.
During observation of the ankle wound treatment the nurse stated he was going to apply Calazine to the wound. The nurse was then observed covering the wound base with Calazine, then applied the silver alginate dressing. On [DATE] review of the physician orders revealed an order for the treatment for the Left ankle wound, in effect since [DATE], which included: Calazine to periwound area and Silver alginate to wound base.
The periwound is the tissue surrounding the wound.
On [DATE] at 2:30 PM surveyor reviewed the concern with the unit nurse manager #8 that the nurse had failed to follow the wound care orders as evidenced by applying the Calazine to the wound base of the ankle pressure ulcer rather than the periwound as ordered; and failed to apply the Calazine to the edges of the sacral wound as ordered.
On [DATE] at 2:57 PM surveyor reviewed with the DON the concerns regarding the development of the pressure ulcers for Resident #110 including: failure of a physician or NP to assess the resident's wounds for several weeks; failure to re-evaluate the need for supplementation when a protein supplement ordered due to the presence of the wounds expired; failure of staff to provide g-tube feedings as ordered; and failure to complete all the steps of a dressing change as ordered.
2) On [DATE] review of Resident #82's medical record revealed a skin integrity report dated [DATE] that documented a stage 2 pressure ulcer on the the right lower extremity measuring 3 cm x 1.5 cm. No further documentation was found on this Skin Integrity Report. A corresponding progress note, dated [DATE] at 11:02 AM and written by the unit nurse manager #8, revealed the following: Pt has stage 2 pressure area to right inferior lower leg. Area measures approx. 3 cm X 1.5 cm. Drainage appears purulent and is malodorous.
Purulent drainage and malodorous odor are indicators that a wound may be infected.
On [DATE] further review of the medical record revealed an order, dated [DATE], to notify MD/NP or wound[TRUNCATED]
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0711
(Tag F0711)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a) A medical record review for Resident #114 on 11/19/19 at 9:07 AM, revealed the resident was admitted on [DATE] following a s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a) A medical record review for Resident #114 on 11/19/19 at 9:07 AM, revealed the resident was admitted on [DATE] following a surgical intervention for an abdominal abscess. The resident had the following diagnoses: End Stage Renal Disease (ESRD) with dependence on hemodialysis (a process to clean the blood when the kidneys are not able), Diabetes Type II, Thyroid Disease, high blood pressure, other pulmonary (lung) blood clot, and a weak left leg affecting mobility.
A review of the physician's order summary for 11/2019, revealed an order dated 10/22/19, for Warfarin (anticoagulant) 5 mg in the evenings on Tuesday, Wednesday, Thursday, Saturday, and Sunday and 2.5 mg on Monday and Friday to repeat PT/INR on 10/25/19 and call the physician. Another order written on 10/22/19, was for an INR (International Normalized Ratio) every Monday and to start on 10/28/19. However, in reviewing the PT/INR results there were no results for 10/25/19. Review of progress notes revealed no information regarding a lab test on 10/25/19 or that the resident refused the laboratory test.
Anticoagulants are medications that decrease the body's ability to clot the blood and therefore increases the risk for bleeding. A person receiving certain forms of these medications, such as warfarin may have their blood closely monitored with a laboratory test referred to as PT/INR. The PT (Prothrombin time) which is the time, in seconds, it takes for the blood to clot and may be expressed in the form of the INR (International Normalized Ratio). The physician uses these results to determine the amount of the anticoagulant to be given.
An interview with Registered Nurse (RN) #42 on 11/19/19 at 10:55 AM, revealed that the staff nurses were not allowed to draw blood, and that a Phlebotomist came to the facility to perform blood draws.
On 11/19/19 at 11:09 AM, and interview with RN #43, revealed the process for reviewing orders. She stated that the physician writes an order and then it is flagged for the nurse to review and at that time the nurse will complete any laboratory orders. When asked about a lab order for Resident #114 to have a blood draw on 10/25/19, the nurse pulled the order up and showed the surveyor that the medication order does not show the special instruction (which is where the order to draw the lab on 10/25/19 was written). She tried another view in the computer and the special instruction did not show up. She stated if it had they would need to call the doctor and add a new order for the lab work. Then they would complete a lab slip and place the resident's name in a notebook for the lab.
The DON was made aware of the concerns on 11/21/19 at 1:28 PM.
2b) A medical record review on 11/19/19, revealed a physician's order summary dated 10/1/19 - 11/30/19, revealed an order written 10/29/19, by CRNP #21 Midodrine HCL 10 mg (milligram) tablet, Give 1 tablet by mouth every 8 hours as needed for hypotension (low blood pressure), BP (blood pressure) < (less than) 90 systolic (top blood pressure number) and give before dialysis times on HD (hemodialysis) days. There was no order for blood pressure monitoring for this order.
On 11/19/19 at 1:38 PM, during an interview with CRNP #21, she stated that she did not indicate specific times to give the Midodrine because the resident's dialysis schedule may change. The CRNP #21 was informed that the Medication Administration Record indicated that the resident was not receiving the medication every time she had dialysis and CRNP #21 stated the resident must not have needed it those days. When ask about combining the order she stated that the nurses are made aware in report and she is sure they can see the order to give it in the MAR.
On 11/19/19 at 2:49 pm, during an interview with RN #50, reported she was not aware that Resident #114 was to receive Midodrine before dialysis. She showed the surveyor on her computer the view she had in the eMAR which was when a resident was due for a routine medication that medication turned green and when it was overdue it turned red. However for an as needed order, such as the Midodrine it was under another tab and did not indicate if a resident was due because it was only as needed. She reported that this was the first time she had been assigned resident and was not told in report about the Midodrine being given before dialysis.
During an interview with Assistant Director of Nursing (ADON) on 11/19/19 at 3:04 PM, revealed she agreed that the staff would not be aware of this order the way it was written and stated it should have been written as two separate orders for staff to be able to properly administer the medication.
The DON was made aware of the concerns on 11/21/19 at 1:28 PM.
2c) A medical record review for Resident #114 on 11/19/19, revealed on the physicians' order summary for 10/2019, an order for wound care. CRNP #20 wrote an order on 10/23/19, for the sacral wound, right buttocks wound, left inferior buttock, and left superior buttock to be cleansed with a cleanser and then apply hydrogel and place an optifoam dressing on the wounds.
An interview with the DON on 11/22/19 at 1:29 PM, revealed that she did not agree with combining the orders for several wounds and had spoken with the corporate wound care nurse regarding CRNP #20's style of writing the orders. She stated there was a concern that something will be missed and when one area had healed it can be confusing to the staff. The DON was informed that according to the Skin Integrity Sheets (a form used to document all aspects of the wounds on a weekly bases for 10 weeks) the wound on the left superior buttocks was healed on 11/13/19, yet staff continued to sign the treatment as being completed until 11/20/19, when the order was discontinued.
1b) On 11/19/19 review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive, chronic kidney disease, high blood pressure, diabetes and lung disease. The resident has had a g-tube since 2018 although the resident does consume meals by mouth. Review of the 8/3/19 minimum data set assessment revealed the resident requires extensive assist from staff for bed mobility and eating. The resident's weight in June 2019 ranged from 124.8 - 130.4 lbs. In August 2019 the resident developed a pressure ulcer on the left ankle.
On 9/5/19 Nurse #40 completed a change in condition note that revealed the presence of a skin wound on the resident's backside (sacral area). The note revealed the primary care nurse practitioner was made aware and wanted the wound nurse to evaluate the patient. The corresponding Skin Integrity Report revealed an in house acquired pressure ulcer, stage 2 measuring 1 cm in length with a width of 0.
Further review of the medical record revealed the wound nurse practitioner gave an order for sacral wound care on 9/6/19. Review of the care plan revealed it was updated on 9/6/19 to include the presence of the sacral wound and resident to be seen on wound rounds was added to the interventions.
Further review of the medical record failed to reveal documentation that the wound nurse assessed the resident's new pressure ulcer when she was scheduled to be in the facility for wound rounds on Wednesday September 11 or 18, 2019. On 11/27/19 at 9:28 AM the wound Nurse Practitioner (NP) #20 reported she was in the facility on September 11 and 18, 2019 but was not sure why she did not see the resident.
Further review of the medical record revealed the resident was seen by the primary care physician #44 on 9/18/19. Review of the primary care physician progress note for 9/18/19 date of service failed to reveal documentation regarding the presence of either the ankle or the sacral wound.
Further review of the medical record failed to reveal documentation that a physician or a nurse practitioner assessed the residents sacral wound from the time it was first documented on 9/5 through 9/24/19.
Further review of the medical record revealed the wound nurse practitioner (NP) #20 assessed the resident on 9/25/19. Review of the progress note for this visit revealed the left ankle wound as being 1.9 x 3.1 x 0.1 cm stage 4 and the sacral wound 3 x 4 x 0.1 cm with heavy drainage and a stage 3.
Further review of the medical record revealed that on 10/9/19 the resident was again seen by the primary care physician. This note revealed documentation under Physical Exam Skin section that was identical to the assessment completed by the wound NP #20 in her 9/25/19 note. There is no notation that these measurements were from the 9/25/19 NP note. Interview with the primary care physician (PCP) #44 on 11/26/19 at 10:11 AM revealed that he was aware the resident currently had sacral and ankle ulcers. The PCP confirmed that he does not assess pressure ulcers every time he sees the resident and went on to state that they have a wound nurse that comes once a week. The PCP went on to confirm that he did not measure the resident's wounds as indicated in the 10/9/19 note, stating that he goes with the measurements provided by the wound nurse.
On 11/27/19 surveyor reviewed the concern with the medical director that the physician failed to assess a newly identified pressure ulcer and concerns regarding the physician's documentation of the wound assessment without identifying that the assessment was two weeks old and had been completed by a NP. Based on medical record review, interviews and observations it was determined that the facility failed to ensure primary care physicians reviewed the resident's total program of care as evidenced by: 1a) failure to accurately address the presence of chronic venous stasis wound with failure to sign orders related to prescribed treatment changes to the wound (Resident #101) and 1b) failure to address the presence of two pressure ulcers, one of which had been identified by staff more than a week prior to the physician's visit but had not yet been assessed by a physician or a nurse practitioner (Resident #110); and failure to ensure the physician's documentation was current and accurate as evidenced by documenting a wound assessment in his note and failing to identify that this assessment had been completed two weeks prior by a nurse practitioner (Resident #110). This was found to be evident for 2 out of 10 residents (Resident #101 and #110) reviewed for pressure ulcers during the survey; 2) failure to ensure that physicians orders were written in a manner that ensured the resident was getting the care and services needed as evidenced due to a physician's order for a medication combined with a laboratory test order for a resident on anticoagulant therapy, a medication order for Midodrine to be given as needed for low blood pressure was combined with an order for Midodrine to be given on dialysis days before treatment, and orders for wound treatment included several wounds in one order. This was evident for 1 of 1 resident (Resident #114) reviewed for dialysis services.
The Findings Include:
1a) Review of Resident #101's medical record on 12/3/2019 revealed that the resident had developed right lower leg ulcer associated with venous stasis disease and was being seen at a local wound clinic once per week beginning on 6/17/19. Review of the wound clinic consultation reports revealed that the facility did not transport the resident to the local wound clinic for 4 weeks. Resident #101 was absent from attending the wound clinic from 8/13/19 to 9/10/19. The care directed by the wound clinic was not maintained during Resident #101's absence from the weekly wound clinic visits.
A nurse's note was written on 8/20/19, included wound appt rescheduled due to w/c being too wide to fit on transportation van. There was no indication in progress notes that the resident's attending physician was notified. A telephone order was created by the Unit Manager #5 at 3 PM on 8/20/19 written as; Wound care: RLE [right lower extremity] clean with wound cleanser, apply Calcium Alginate to base, cover with ABD pad and wrap with Kerlix PRN (as needed) Mon, Wed, Fri, PRN Unna Boot not in place. Review of the attending physician's note dated 8/20/19 7:41 PM did not reveal documentation related to the skin/wound status for Resident #101. The attending physician had failed to provide an assessment and evaluation related to the dressing change phone order. As of 12/3/19 there was no indication that the attending physician had signed the telephone order.
Based on medical record review, Resident #101 had an above the knee left leg amputation in December of 2018. Observations of the resident (initial on 11/15/19) revealed that Resident #101 had a left leg stump and full right leg with bandage/wrap on the lower right extremity. Review of the attending physician's 8/20/19 note revealed inaccurate data. The physician's note under Past Medical History indicated the resident had bilateral leg amputation and wound right stump. Under Physical Exam, the physician's note indicated the resident had an open area small right toe. Review of skin integrity reports indicated that the right 2nd toe area was healed on 5/15/19. Under the plan section the physician wrote local dressing care of wound right ankle per wound nurse. The resident was not being seen by the wound nurse as the resident was to have weekly visits at the wound clinic.
There was no evidence that the attending physician or Certified Registered Nurse Practitioner (CRNP)'s reviewed the weekly wound consultation reports. Review of a 8/13/19 wound consultation report revealed the venous leg ulcer was classified as a full thickness without exposed support strictures wound measuring; length (L) 9.0 cm x width (W) 2.8 cm x depth (D) 0.1 cm. The report included the total area of the wound 19.782 cm and the volume at 1.979 cm. Additionally, details of the wound were provided as to amount of drainage, necrotic tissue and the appearance of the skin around the wound. The report indicated the wound to be cleansed with soap and water, apply medihoney w/ Calcium alginate dressing and protect surrounding skin with calmoseptine. The dressing change frequency indicated Do not change dressing for One Week. For edema control Unna Boot compression therapy was applied to the right lower extremity. (Unna Boot itself is a compression dressing, usually made of cotton, that has a zinc oxide paste applied uniformly to the entire bandage, which can be used for the treatment of venous stasis ulcers). The resident was to return to the clinic in 1 week. Additional instructions included Do not remove dressing unless you are ready to put back on another Unna boot! PLEASE
During the resident's 4-week absence from attending the wound clinic the use and/or prescription for Unna boot was never addressed. Additionally, the staff failed to follow the order as prescribed on 8/20/19. The resident's attending physician and CRNPs failed to address/evaluate the care of the right lower leg chronic venous stasis ulcer. Upon the resident's return to the clinic on 9/10/19, maggots were found in the wound and based on a tissue culture the wound was found to be infected with pseudomonas and proteus mirabilis as this was documented in the 9/10/19, and 9/17/19 wound consultation reports.
The medical director was informed of the concerns on 12/4/19 at 1:05 PM as to the lack of care for Resident #101 and the erroneous documentation that was included in the physicians' progress notes. The medical director indicated that the facility's corporation makes the staff utilize pre-templated progress notes and acknowledged the erroneous data as written for Resident #101.
Cross reference to F684 and F686, Resident #101
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
1B) On 11/15/19 an interview was conducted with Resident #49. At 1:04 PM, during the surveyor interview, Geriatric Nursing Assistant (GNA) #7 entered the resident's room without knocking on the door. ...
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1B) On 11/15/19 an interview was conducted with Resident #49. At 1:04 PM, during the surveyor interview, Geriatric Nursing Assistant (GNA) #7 entered the resident's room without knocking on the door. On 11/15/19 at 1:27 PM, during the surveyor interview with Resident #49, GNA #7 again entered the resident's room without knocking. At that time, Registered Nurse (RN) #8, Unit Manager also entered Resident #49's room without knocking. GNA #7 and RN #8 failed to knock on the resident's door and request permission from Resident #49 prior to entering his/her room.
The Director of Nursing was made aware of the above findings on 11/22/19 at 3:57 PM.
3) Review of Resident #17's medical record revealed the resident was admitted to the facility in August 2018 with an indwelling urinary catheter.
Observation of Resident #17 on 12/5/19 at 10:40 AM and 12/6/19 at 8:25 AM, revealed the resident's urinary catheter bag was not covered. During interview with Resident #17 on 12/6/19 at 8:25 AM, the resident asked if he/she would like the urinary catheter bag covered. The resident stated yes, especially when he/she has visitors. The Unit Manager #15 was brought to the resident's room on 12/6/19 at 8:29 AM and confirmed the surveyor's findings.
Interview with the Director of Nursing on 12/6/19 at 10:48 AM confirmed the facility staff failed to provide the resident with the most dignified existence.
2) On 11/14/19 at 2:44 PM surveyor observed from the hallway a sheet of paper titled NOVEMBER WEIGHTS posted on the wall next to the posted nurse staffing. This sheet included an alphabetical list of the resident's last names, their room numbers and hand written weights for 6 of the 22 residents listed.
On 11/14/19 at 2:48 PM, after providing a copy of the NOVEMBER WEIGHTS paper to the surveyor, Nurse #13 was observed to hang the sheet back up on the wall. When asked if that is where the list is normally kept the nurse reported that staff were working on obtaining the weights today.
On 11/14/19 at 4:14 PM surveyor again observed the unit where the NOVEMBER WEIGHTS had been posted and noted that the list was no longer visibly posted on the wall.
On 12/5/19 surveyor reviewed the concern regarding the posting of resident's weights in a visible area with the Director of Nursing and the Administrator #3.
Based on surveyor observation, record review and interview, it was determined that the facility staff failed to: 1) protect and value residents' private space by failing to knock and request permission before entering a resident's room. This was evident but not limited to 2 of 29 residents (Resident #63 and #49) observed on two different units during the initiation of the survey; 2) respect the residents' dignity as evidenced by posting a sheet with resident names and their weights on the wall of the nursing unit next to the posted staffing, in an area visible to residents and visitors. This was found to be evident on 1 of the 3 nursing units; 3) provide a resident with the most dignified existence (Resident #17). This was evident for 1 of 29 residents selected for review during the annual survey process.
The findings include:
1A) An interview was conducted with Resident #63 in the resident's room on 11/14/19. At 3:20 PM vocalizations of knock knock was heard and without any acknowledgement from the 2 residents in the room before the employee had entered the room. The surveyor looked up and the employee was by the bedside of the resident in the B-bed. The employee informed the residents that she was making rounds and did the residents have anything to share with her. Upon surveyor questioning the employee was identified as the clinical reimbursement coordinator (Staff #11). After staff #11 left the room both residents indicated not knowing whom she was. They both indicated not seeing this employee previously.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on observation, interview and review of pertinent documentation it was determined that the facility failed to ensure grievances were addressed in a timely manner. This was found to be evident fo...
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Based on observation, interview and review of pertinent documentation it was determined that the facility failed to ensure grievances were addressed in a timely manner. This was found to be evident for 1 out of 4 residents (Resident #369) reviewed for dignity.
The findings include:
On 11/14/19 at 3:11 PM Resident #369's representative (RR) reported having reviewed various concerns with the facility staff.
On 12/4/19 review of the Grievance/Concern Form revealed the social worker #9 received a concern from the RR on 11/7/19 regarding food, housekeeping and nursing services. The issue regarding the food was addressed in a timely manner on 11/8/19. The issue regarding housekeeping was not addressed until 11/17/19, this was 10 days after the initial complaint. The issue regarding nursing services was documented as being assigned to the unit nurse manager #8 on 11/14/19 with resolution on 11/22/19.
Further review of the nursing concerns revealed they involved night shift staff's failure to provide care. Part of the resolution was an inservice of staff. Review of the inservice sheet revealed it occurred on 11/19/19 and failed to reveal documentation that night shift staff was included in the in-service. On 12/4/19 at 1:26 PM the unit nurse manager #8 reported that she had spoken with the RR on the day the incident occurred, but had been unaware at that time of the Grievance/Complaint form. Nurse manager confirmed she had not spoken with night shift and that the inservice was completed on 11/19/19.
Review of the facility's policy regarding Grievance/Concern, with a revision date of 7/1/19, revealed that upon receipt of a grievance/concern the Grievance/Concern Form will be initiated by the staff member receiving the concern and the appropriate department manager will be notified. The department manager will contact the person filing the grievance, investigate, take corrective action as needed and notify the person filing the grievance of resolution within 72 hours [3 days].
On 12/4/19 at 11:09 AM Social Worker (SW #9) reported that the first person taking the complaint does the paperwork then brings it to her. The SW then makes sure the complaint goes to the appropriate staff to be addressed. The department head will take action and then return the form to the SW department. SW #9 confirmed she spoke with the RR on 11/7/19. When asked about a process for follow-up of the grievance forms the SW #9 responded that sometimes she mentions it at a group meeting, and time to time will send an email.
The concern regarding failure to address grievances in a timely manner was addressed with the Director of Nursing and the Administrator (Staff #3) on 12/5/19 at approximately 5:30 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that the facility 1) failed to document the discharge of a resident in the medical record including the reason for the transfer and...
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Based on medical record review and staff interview it was determined that the facility 1) failed to document the discharge of a resident in the medical record including the reason for the transfer and information provided to the receiving provider to ensure a safe and effective transition of care and 2) failed to ensure a physician's discharge summary was completed following a resident's discharge from the facility. This was evident for 1 of 13 residents (Resident #126) reviewed for accidents and 1 of 4 residents (Resident #119) reviewed for discharge.
The findings include:
1) On 12/3/19 at 12:52 PM, a review of Resident #126's medical record revealed the resident was discharged from the facility to another facility in July 2019. On 7/5/19 at 3:56 PM, the social worker documented that the resident was accepted at another facility's dementia unit and indicated the resident was discharged . There was no further documentation in the resident's medical record regarding the basis for the transfer, or that the appropriate information had been communicated to the receiving health care facility. Continued review of the medical record failed to reveal evidence that a discharge summary for Resident #126 had been completed by the physician.
On 12/3/19 at 3:35 PM, during an interview, the Director of Nursing (DON) was made aware of the findings. The DON stated that the physician's discharge summary would be in the resident's electronic record if it had been completed and he/she would expect to see a transfer summary in the medical record when a resident is transferred to another facility. The DON stated he/she would check and see if a transfer summary had been completed on paper. The DON failed to provide any further evidence that a transfer summary had been completed for Resident #126 upon his/her transfer to another facility.
2) On 12/4/19 at 8:42 AM a review of Resident #119's closed medical record revealed documentation that Resident #119 was admitted to the facility in August 2019 and discharged from the facility on 8/20/19. Continued review of Resident #119's medical record failed to reveal a discharge summary had been written by the physician when the resident was discharged from the facility. On 12/4/19 at 11:00 AM, the Director of Nursing confirmed the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on observation, interview and medical record review it was determined that the facility failed to comprehensively assess the resident's activity preferences as evidenced by failure to interview,...
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Based on observation, interview and medical record review it was determined that the facility failed to comprehensively assess the resident's activity preferences as evidenced by failure to interview, or attempt to interview, the resident's responsible party during the assessment of the resident's interests for the purposes of the comprehensive MDS assessment; and failed to include items that had been identified by staff as being enjoyed by the resident in the Staff Assessment of Daily and Activity Preferences section of the MDS. This was found to be evident for 1 out of 7 residents (Resident #110) reviewed for activities.
The findings include:
The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident
1) Review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive and lung disease. The resident is unable to independently ambulate and requires extensive assistance of staff for bed mobility, dressing, eating and personal hygiene. The resident has severe cognitive impairment and unclear speech.
The resident was observed in bed on the following dates and time: 11/14/19 at 3:10 PM; 11/18/19 at 9:58 AM and 10:34 AM; 11/19/19 at 12:53 PM; and 11/20/19 at 10:09 AM. The television was on during some of these observations but no observations were made of music playing or visits by activity staff.
On 11/21/19 at 4:52 PM interview with activity aide #60 revealed she visits the resident a couple times a week and attempts to have conversations with the resident but the resident usually only responds with yes or no. The aide indicated she was aware that the resident did have a relative that the aide has spoken with on occasion.
Review of the 10/28/19 Recreation Comprehensive Assessment completed by activity aide #60 revealed the resident is seen weekly for room visits for sensory stimulation, looks at the television, listens to music and makes some eye contact to picture flash cards, receives massaging hands with lotion, enjoys staff spiritual reading and will sit in the day room watching television.
Review of the 11/1/19 annual Minimum Data Set (MDS) assessment revealed Section F Preferences for Customary Routine and Activities was coded 0 indicating the resident is rarely/never understood and family/significant other was not available. Section F 0800 Staff Assessment of Daily and Activity Preferences indicated none of the listed preferences applied to the resident. Some of the listed items that were not checked included: listening to music and participating in religious activities or practices.
On 11/22/19 at 3:34 PM the activity director reported that the activity assessment staff would be expected to attempt to contact the family listed on the facesheet and that these attempts should be documented. Surveyor reviewed the concern that there was no documentation found to indicate any attempt had been made to contact the family during the completion of the activity assessment.
As of time of survey exit on 12/11/19 no additional documentation had been provided to indicate attempts had been made to contact the resident's family during the completion of the MDS annual assessment.
Cross reference F 679
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined the facility staff failed to conduct an accurate assessment by failing to assess a resident's cognition, mood, behaviors and partic...
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Based on medical record review and staff interview it was determined the facility staff failed to conduct an accurate assessment by failing to assess a resident's cognition, mood, behaviors and participation in assessment on a quarterly Minimum Data Set (MDS) assessment. This was evident for 1 of 13 residents (Resident #126) reviewed for accidents.
The findings include:
The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident
Review of Resident #126's medical record on 12/3/19 at 12:52 PM revealed an incomplete MDS (minimal data set) assessment. Review of Resident #126's quarterly MDS with an ARD (assessment reference date) 6/12/19 revealed Section C, Cognitive Patterns, Section D, Mood, and, Section E, Behavior were not assessed. Section Q, Participation in Assessment and Goal Setting, was incomplete; Q0100. Participation in Assessment, questions A., B., and C., were not coded as being assessed. Review of the MDS, Section Z, signature of persons completing the assessment indicated Section C, D, E and Q were completed by the social worker on 6/18/19.
On 12/10/19 at 2:46 PM, during an interview, when asked why the Resident #126's MDS, Sections C, D, E and Q were incomplete, the Social Worker #9 stated that if the MDS had been opened well after the ARD date, he/she could not go back to reference it.
The Director of Nurses was made aware of the above findings on 12/3/19 at 3:35 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0642
(Tag F0642)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined the facility staff failed ensure each MDS assessment was conducted with the appropriate participation of health professionals, sign...
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Based on medical record review and staff interview it was determined the facility staff failed ensure each MDS assessment was conducted with the appropriate participation of health professionals, signed and certified that the assessment was completed. This was evident for 1 of 7 residents (Resident #4) reviewed for Unnecessary Medication.
The findings include:
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status.
Review of Resident #4's medical record on 12/4/19 at 10:10 AM revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) 11/6/19. Section C Cognition indicated not assessed and Section D Mood contained none of the required information. Both sections were signed by Staff #9 a Social Worker on 12/2/19 as completed, not within 14 days of the ARD.
Staff #9 was interviewed on 12/4/19 at 11:14 AM and confirmed these findings. When asked why the sections were not completed, she indicated that the Clinical Reimbursement Coordinator (CRC) failed to notify her when the assessments were due.
During an interview on 12/4/19 at 2:50 PM, Staff #11 and #12 the CRC's were made aware and confirmed that Sections C and D of Resident #4's Quarterly MDS with the ARD 11/6/19 were not completed. They indicated they were not aware that it had not been done until the surveyor asked. When asked how this was missed, they indicated that this MDS was not scheduled. They confirmed that Resident #4's quarterly MDS assessment with the ARD 11/6/19 was not certified as completed and went on to say there is a glitch in the electronic medical record system and that sometimes the assessments do not come up to be scheduled.
The facility failed to have an effective system in place to ensure that each assessment was completed timely, coordinated with appropriate participation of health professionals, signed and certified as completed by a registered nurse.
The Director of Nursing was made aware of these concerns on 12/6/19 at 11:07 AM.
Cross reference F 641.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on medical record review and interview it was determined that the facility failed to ensure a resident with a diagnosis of serious mental illness, which was made after admission, was referred to...
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Based on medical record review and interview it was determined that the facility failed to ensure a resident with a diagnosis of serious mental illness, which was made after admission, was referred to an appropriate state-designated mental health authority. This was found to be evident for 1 out of 2 residents (Resident #82) reviewed for PASARR during the survey.
The findings include:
On 11/15/19 review of Resident #82's medical record revealed a PASARR completed prior to admission in 2016. Review of this PASARR revealed the resident did not, at that time, have a serious mental illness.
Further review of the medical record revealed a Minimum Data Set (MDS) assessment, dated October 2019, which included a diagnosis of unspecified psychosis not due to substance abuse or known physiological condition.
Further review of the medical record failed to reveal documentation that a referral had been made to the state-designated mental health authority for review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 12/4/19 at 8:42 AM, a review of Resident #119's medical record was conducted and revealed documentation that the resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 12/4/19 at 8:42 AM, a review of Resident #119's medical record was conducted and revealed documentation that the resident was admitted to the facility on [DATE] for rehabilitation following right knee surgery. The resident's admitting diagnosis included osteoarthritis in the right knee, obesity, hypertension and the presence of an unspecified artificial knee joint. Review of the medical record revealed a care plan Patient requires assistance for mobility related to right knee surgery, with the goal Resident will utilize side rails independently and with assistance for turning and repositioning while in bed; transferring to/from bed, that had the intervention side rails to enable turning and repositioning in bed was initiated on 8/16/19. There were no other interventions to address the resident's mobility or care related to his/her right knee.
Continued review of the medical record failed to reveal documentation that an initial baseline care plan had been developed within 48 hours of admission and given, along with summary of the resident's medication to the resident and/or resident representative.
On 12/4/19 at 11:00 AM, the Director of Nurses confirmed the findings.
2) Resident #4's medical record was reviewed on 12/4/19 at 10:10 AM. The resident had diagnoses including but not limited to paraplegia, osteomyelitis (bone infection), anxiety and pressure ulcers. The surveyor was unable to locate a baseline plan of care that identified the individualized care and preferences to meet Resident #4's unique needs.
During an interview on 12/4/19 at 12:27 PM Staff #9, a Social Worker, was asked where to find Resident #4's baseline care plan. She indicated that a Post admission Rounds was done and referenced a form in Resident #4's record labeled Post admission Patient-Family Conference form. She stated that she did not know what the surveyor meant by baseline care plan.
Resident #4's Post admission Patient-Family Conference form dated 8/6/19 was reviewed. Section A.2b. stated This Baseline Person-Centered Care Plan is developed within 48 hours and is reviewed at the Post admission Patient/Family Conference and updated as indicated. The form indicated Resident #4, Social Services, Nurse UM (Unit Manager), and Recreation were in attendance. The form included the resident's expected length of stay, discharge needs, discharge plans and that Resident #4 had medication and wound care education needs. It also indicated that the resident received a copy of the form.
The plan failed to include the initial goals and objectives for Resident #4 based on admission orders, physician orders, dietary orders, therapy services and social services nor medications and dietary instructions. It did not include the services or treatments to be administered by the facility for the provision of effective and person-centered care to Resident #4.
The Director of Nursing was made aware of these concerns on 12/6/19 at 11:07 AM.
Based on medical record review and interview it was determined that the facility failed to 1) have a system in place to ensure resident's and or the resident's representative (RR) were informed of the initial care plan meeting, provide a summary of the baseline care plan that included the required information (#4), ensure base line care plans were developed within 48 hours of admission, and care plan meetings were held after admission MDS assessments were completed. This was found to be evident for 3 of 104 residents ($369, #4, and #119) reviewed for care plans.
The findings include:
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
1) On 11/15/19 review of Resident #369's medical record revealed the resident had severe cognitive impairment and required supervision with eating, extensive assist for bed mobility and dressing, and was totally dependant on staff for bathing. On 11/15/19 at 8:50 AM the resident's representative (RR) denied knowledge of a care plan meeting or having received baseline care plan information.
On 12/4/19 at approximately 12 noon the social worker #9 reported that there is a Post admission Patient Family Conference that is considered the first care plan meeting. She went on to report that the only documentation provided to the resident or the RR at this meeting would be a copy of the Post admission Patient-Family Conference note. If the resident or RR requested a copy of the care plan, or list of medications, SW reported that she would provide this information.
On 12/04/19 at 12:27 PM SW #9 was asked where to find documentation of the resident's baseline care plan. The SW reported that Post admission Rounds are done and referenced the Post admission Patient-Family Conference form in the resident's record. SW went on to report that she refers to this process as Post admission Rounds because the treatment team goes from room to room to meet with the resident. SW confirmed that the resident or the RR are not invited ahead of time to attend. SW went on to report that if resident and or RR is there they are included, if they happen to be out of the room at that time, the team discusses their plan of care and provides the resident/RR with a copy of the Post admission Patient-Family Conference form afterward. SW confirmed that the meeting is not rescheduled to include the resident or the RR and that no advance notification is given.
Further review of the medical record revealed care plans were initiated on 11/2 and 11/4/19.
Review of the Post admission Patient-Family Conference form revealed the following: Objective: To review and communicate the person-centered baseline care plan and identify further patient and family expectations and Documentation of the Patient/Family conference serves as the baseline care plan review and care plan meeting note. Further review of the Post admission Patient-Family Conference note for Resident #369, dated 11/8/19, revealed the nurse unit manager, a representative from rehab and the dietitian attended the meeting. The resident and the RR did not attend the meeting. The note indicated prior living situation, current level of function and services and or treatments were discussed (this was indicated by check marks only, no details documented). Under the section for comments the SW wrote: SW in touch with [resident's RR], and also checked the box Copy given to resident and or resident representative.
On 12/4/19 at 12:22 PM when asked how the copy of this note was provided to the resident and or the RR the SW reported that she folds a copy of the Post admission Patient-Family Conference form so just the resident's name is showing and leaves it at the bedside. SW went on to confirm that she does not inform resident's RR that this paperwork is in the resident's room.
Further review of the Post admission Patient-Family Conference note failed to reveal any documentation regarding initial goals of the resident, a summary of the resident's medications and dietary instructions or any specifics regarding services and treatments to be administered by the facility and personnel acting on behalf of the facility.
On 12/04/19 at 1:55 PM SW #9 confirmed that the Post admission Patient Family Conference is the first care plan meeting and that the next care plan will not be scheduled until after the quarterly MDS assessment is completed. For Resident #369 this is scheduled to be in February 2020. SW #9 confirmed that if the Post admission Patient Family Conference is held prior to the completion of the admission Minimum Data Set (MDS) assessment the next care plan meeting will not be held until after the quarterly MDS assessment is completed.
On 12/5/19 surveyor reviewed the concern with the Director of Nursing and Administrator #3 regarding the failure to include the resident and or the RR in the initial care plan meeting; failure to provide required baseline care plan information and failure to ensure care plan meeting are held after completion of admission MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
2) On 12/4/19 at 1:26 AM, during an interview, a family member of Resident #14's voiced concerns that Resident #14 was no longer receiving rehab services even though the resident still needed services...
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2) On 12/4/19 at 1:26 AM, during an interview, a family member of Resident #14's voiced concerns that Resident #14 was no longer receiving rehab services even though the resident still needed services. On 12/5/19 at 10:08 AM, during an interview, Resident #14 stated that he/she was upset because he/she would have rehab for a while, then when the goals were met and he/she would be discharged from therapy. Resident #14 stated that the staff was supposed to assist resident to walk everyday but it wasn't being done. The resident stated that when he was discharged from therapy, the therapist showed the staff on the unit how they were to walk with the resident and the unit manager signed the functional maintenance program contract and that was the last time someone walked with the resident. Resident #14 stated that the staff would say they would walk with the resident when they got a chance and they never got a chance.
On 12/5/19 at 9:00 AM, a review of the resident's medical record revealed Resident #14 had diagnosis that included muscle weakness and documentation indicating the resident was unable to walk independently. Review of Resident #14's physician progress notes revealed, on 10/17/19, 11/18/19, 11/26/19 and 12/1/19, the physician documented the resident was post-surgery with inability to walk, right sided weakness and leg weakness. On 11/27/19, in a hospital discharge note, the physician documented Resident #14's discharge diagnosis included paraplegia (impairment in motor or sensory function of the lower extremities) with cervical spine injury.
Review of Resident #14's care plans failed to reveal a comprehensive, resident centered care plan had been developed to address Resident #14's limited mobility and continued review of the resident's medical record failed to reveal evidence the resident was on a FMP.
Further review of Resident #14's medical record revealed the resident had received physical therapy (PT) from 9/18/19 through 10/17/19. Resident #14's PT Recertification/Monthly Summary, for 9/18/19 - 10/17/19 indicated the resident had reached his/her therapy goals. On 12/6/19 at 12:41 PM, during an interview, the rehab manager, Staff #16, stated that Resident #14 was discharged from therapy on 10/10/19 because the resident had plateaued. Staff #16 stated after the resident was discharged from therapy, staff training for ambulation with the resident was done, however there was no documentation to this effect and no evidence the resident was on a FMP program. Staff #16 confirmed that the resident should have been on an FMP program when discharged from therapy. On 12/6/19 at 1:27 PM, the Staff #16 stated that Resident #14 would be re-evaluated for therapy and staff would be retrained for Resident #14's FMP program.
Based on medical record review, resident, family and staff interview and observation it was determined that the facility failed to: 1) have an effective system in place to ensure functional maintenance programs were put in place after a resident was discharged from therapy. This was found to be evident for 1 out of 10 resident's reviewed for pressure ulcers (Resident #110) and 1 out of 8 residents (Resident 84) reviewed for activities of daily living; 2) provide the necessary care and follow-up to ensure that residents received the appropriate treatment and services to maintain and/or improve ambulatory status. This was evident for, but not limited to 1 of 8 residents (Resident #14) reviewed for hospitalization.
The findings include:
1a) On 11/19/19 review of the Resident #110's medical record revealed the resident had a history of dementia, failure to thrive, chronic kidney disease, high blood pressure, diabetes and lung disease. The resident had a g-tube since 2018 although the resident did consume meals by mouth. Review of the 8/3/19 minimum data set assessment revealed the resident required extensive assist from staff for eating and bed mobility and had functional limitation of range of motion for the lower extremities on both sides of the body. Review of the 11/1/19 minimum data set assessment revealed limitations of range of motion on both sides of the body for both the upper and lower extremities. In August 2019 the resident developed a pressure ulcer on the ankle. In September 2019 the resident developed a sacral pressure ulcer.
On 11/22/19 further review of the medical record revealed the resident had received physical therapy services from 9/12/19 thru 10/10/19. There was a physician order, dated 10/11/19, for Physical therapy Clarification order: Patient is D/C [discharged ] from skilled PT [physical therapy] services to continue with FMP [functional maintenance program] under nursing care. FMP and caregiver education completed at this time.
On 11/22/19 the therapy director #16 reported that the therapist will review the FMP with nursing prior to discharge and that therapy keeps a copy of the FMP and a copy is placed on the resident's chart on the unit. She provided a copy of the Safe Transitions Goals/Functional Maintenance Plan (FMP form), dated 10/11/19, and confirmed that it included instructions to perform passive range of motion (PROM) 3 sets of 10 to both the right and left lower extremities to be done daily, stating that they typically recommend that this is done with morning care. She went on to report that they document that the resident has been discharged and a program is in place.
Further review of the FMP form revealed a total of 3 staff had signed as having been inserviced regarding the resident's FMP, including Geriatric Nursing Assistant (GNA) #29. On 11/22/19 at 11:51 AM review of the staffing sheets revealed GNA #29 was currently assigned to care for Resident #110. During an interview at that time with GNA #29, when asked if the resident was currently on a functional maintenance program the GNA responded: no. However she did go on to report that she does provide range of motion services to the resident's arms and legs, stating they tell us to do range of motion with them. The GNA was unsure if there was documentation regarding the provision of the range of motion services.
Review of the resident's care plans failed to reveal any documentation regarding a functional maintenance program or the provision of range of motion services. No documentation was found in the GNA documentation regarding the provision of FMP/range of motion services for this resident.
On 11/22/19 at 12:06 PM the unit nurse manager #8 reported that when a resident is discharged from therapy the therapist brings the plan to nursing and reviews it with them and staff signs off. She went on to report that therapy puts in the orders for what the FMP is suppose to consist of and that these should go into the POC [point of care - electronic system for GNA documentation] and come up as a task [for GNA completion]. Surveyor then reviewed the concern that therapy put in an order that the resident had been discharged with a FMP but this order did not include the specifics of the FMP. Surveyor also reviewed the concern regarding how the FMP specifics are conveyed to other care givers. The unit manager reported the staff would verbally tell them.
On 11/22/19 at 2:57 PM surveyor reviewed the concern with the Director of Nursing regarding the failure to have a care plan, or orders, for the specifics of the functional maintenance program.
1b) On 11/18/19 review of Resident #84's medical record revealed the resident required extensive assistance for bed mobility and dressing, and is totally dependant for transfers and bathing. The resident has functional limitations in range of motion on the left side for both upper and lower extremities.
On 12/2/19 at 1:55 PM the therapy director #16 reported the resident received physical therapy in March of 2019 and that a maintenance program had been recommended that included ROM as tolerated and bed mobility with the GNA. Therapy director provided a copy of the 3/8/19 Safe Transitions Goals/Functional Maintenance Plan (FMP form) which included the instructions. Two GNAs had signed the form as having been inserviced for this FMP. Previous review of the paper chart had revealed FMP instructions dated 2/22/18. The 3/8/19 FMP sheet had not been found on the paper chart available on the nursing unit.
No documentation was found in the medical record that the FMP established in March 2019 was being implemented by staff. Review of the care plan failed to reveal any documentation about an FMP. The care plan also failed to address the fact that the resident had limited range of motion on the left side.
On 12/3/19 at 11:37 AM unit nurse manager #5 reported that the process for implementing an FMP consists of therapy coming up to the unit, going over the assessment and staff signing off on the instructions to indicate they are comfortable with providing the program. The FMP paperwork is then placed in the resident's chart. The unit manager also reported that she thought therapy put the FMP into the POC system but stated that she would need to follow up [for clarification]. Surveyor then reviewed the concern that the care plan failed to address the FMP with the unit manager.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview it was determined the facility staff failed to ensure a resident recei...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview it was determined the facility staff failed to ensure a resident received proper foot care and treatment. This was evident for 1 of 104 residents (Resident #23) selected for review during the annual survey process.
The findings include:
Review of Resident #23's medical record revealed the resident was admitted to the facility in July 2019. Review of the resident's care plans revealed the resident had a care plan for: resident requires assistance for ADL care in bathing, grooming, dressing.
Review of the resident's quarterly assessment dated [DATE] for Personal Hygiene revealed the resident was a two+ persons physical assist for Activities of Daily Living Assistance.
Observation of Resident #23 on 12/5/19 at 9:15 AM revealed the resident had elongated, thickened toenails on both feet. During interview with the resident at that time, he/she stated the facility staff told her when she was admitted in July 2019, they were going to take care of his/her toenails but no one has.
Review of Resident #23's medical record revealed a physician order on 7/13/19 for podiatry for excessively long toenails. Further review of the resident's medical record revealed no podiatry consults since admission in July 2019.
Interview with the Director of Nursing on 12/6/19 at 10:48 AM confirmed the facility staff failed to ensure the resident had a podiatry consult as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, medical record review and staff interview it was determined the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and ser...
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Based on observation, medical record review and staff interview it was determined the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 of 3 residents (Resident #10) reviewed for position/mobility.
The findings include:
On 11/18/19 at 1:01 PM, an observation of Resident #10 revealed the resident had a left-hand contracture and (limited movement of a joint) observed with nothing in his/her left hand and both legs were observed to be bent at the knees. On 12/2/19 at 10:55 AM, a second observation of Resident #10 revealed the resident had a left-hand contracture and observed with nothing in his/her left hand.
On 12/3/19 at 12:39 PM, review of Resident #10's medical record revealed documentation that Resident #10's diagnosis included a history of traumatic brain injury, paraplegia (impairment in motor or sensory function of the lower extremities) and contractures of muscle, multiple sites. Review of Resident #10's most recent assessment with a reference date of 8/17/19, Section G. Functional Status documented that Resident #10 was dependent on staff for all activities of daily living, including positioning and documented that Resident #10 had functional limitation in range of motion (ROM) on one side of his/her upper extremity, and impairment on both lower extremities.
Review of Resident #10's care plans failed to reveal a plan of care had been developed to address the resident's left-hand contracture and his/her limited range of motion. Continued review of the medical record failed to reveal evidence that Resident #10 was receiving services to prevent further decline in the resident's range of motion.
On 12/3/19 at 2:45 PM, during an interview, the Rehab Services Director, Staff #16, stated that Resident #10 was seen by therapy in March 2019 and, at that point, the resident had a splint for the left hand and would have likely been on a FMP (functional maintenance program), however, Staff #16 stated he/she did not have a copy of the resident's FMP. Staff #16 stated that FMP service depends on the individual needs of the resident and that Resident #10 should have one but could not speak to why Resident #10 did not. Staff #16 stated when a resident is on a FMP program, the therapist trains staff on the resident's FMP, they sign off on it, a copy is placed in the resident's chart and a Rehab keeps a copy. At the time of the interview, Staff #16 reviewed the resident's EMR (electronic medical record) and stated that Resident #10 was discharged from Rehab due to lack of insurance. Staff #16 stated that it was possible the order for resident's hand splint had not been entered into the EMR if the rehab staff had not determined whether the resident was able to tolerate the splint. When asked if the facility had a responsibility to prevent further decline in ROM in a resident with a contracture, Staff #16 stated yes and indicated he/she would look into it.
On 12/10/19 at 2:45 PM, the Administrator, Staff #3, was made aware of the above findings. On 12/11/19, at approximately 3:00 PM, Staff #3 provided the surveyor with a 12/11/19 physician's order for Resident #10, for Occupational Therapy evaluation and treatment as recommended for splinting of left hand, one time a day for contracture management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that facility staff failed to protect a resident, who was dependent on staff for turning and positioning, from falling out of bed d...
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Based on medical record review and staff interview it was determined that facility staff failed to protect a resident, who was dependent on staff for turning and positioning, from falling out of bed during care. This was evident for 1 of 8 residents (Resident #36) reviewed for hospitalization.
The findings include:
Review of Resident #36's medical record on 12/5/19 revealed an SBAR Communication Form (Change in Condition) which documented the resident had a fall on 11/13/19 at 5:40 AM. Review of facility documentation, that was given to the surveyor by the Director of Nursing, revealed the resident apparently rolled from his/her bed when he/she was turned during incontinent care. The report continued, resident b/p (blood pressure) low (96/52) post fall. MD ordered x-ray of the skull to r/o (rule out) bleeds or fx (fracture). The note ended as, staff was reminded to always call for additional help with this resident during care to prevent falls. The resident did not have any injuries as a result of the fall.
Review of the staff assignment sheets for the 11:00 PM to 7:00 AM shift for 11/12/19 to 11/13/19 revealed that GNA (geriatric nursing assistant) #37 was assigned to the resident that shift. GNA #37 was unavailable for interview. An interview was conducted with RN #36 on 12/5/19 at 4:05 PM as RN #36 was the nurse on duty who did the investigation. RN #36 stated that during the care of Resident #36 there was only 1 GNA providing care to Resident #36. After Resident #36 rolled out of bed during care the other GNAs on the floor went to help by getting a Hoyer lift to get the resident back in bed. RN #36 stated that the other GNAs were telling GNA #37 that she should have help when turning and changing the resident. GNA #34 was interviewed on 12/5/19 at 12:11 PM and stated, we have to give incontinent care. He/she requires 2 people to turn him/her.
Review of the admission MDS assessment with an assessment reference date (ARD) of 9/24/19, Section G, Functional Status, coded that the resident was extensive assistance (resident involved in activity, staff provide weight-bearing support) and the resident required two plus staff for support for bed mobility and personal hygiene.
Review of the care plan, resident is at risk for falls: impaired mobility had the intervention, resident to be 2 staff person assistance at all times during care. This was added to the care plan on 11/13/19 even though the admission MDS documented that the resident was a 2+ assist for bed mobility.
The facility failed to produce documentation that a thorough investigation was done and there was no documentation that staff was educated. The only documentation given to the surveyor was an incident report of the fall. The surveyor asked the Director of Nursing (DON) on 12/5/19 at 1:45 PM if there was any follow-up regarding the fall or education to staff and the DON confirmed that was no additional documentation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined the facility failed to provide the necessary care and services for a resident with a suprapubic catheter to prevent urinary tract i...
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Based on medical record review and staff interview it was determined the facility failed to provide the necessary care and services for a resident with a suprapubic catheter to prevent urinary tract infections to the extent possible. This was evident for 1 or 3 residents (Resident #14) reviewed for urinary catheters.
The findings include:
On 12/5/19 at 9:00 AM, Resident #14's medical record was reviewed and revealed the resident, admitted to the facility in 2018, had a suprapubic catheter (hollow flexible tube used to drain urine that is inserted in the bladder through an incision in the belly) for a neurogenic bladder (bladder dysfunction) and a history of recurrent UTIs (urinary tract infections). Review of Resident #14's laboratory test results revealed urine c/s (culture/sensitivity) (tests for bacteria and susceptible antibiotic) lab results reported to the facility on 8/1/19, 9/9/19 and 11/17/19 indicated the resident had a UTI. Review of the resident's medical record revealed documentation that the resident was treated with antibiotics for a UTI in August, September, November and December 2019.
Resident #14's July 2019 MAR (medication administration record) documented that in July 2019, Resident #14 received 3 antibiotics (Nitrofurantoin, 7/1/19 to 7/7/19, Keflex, 7/5/19 to 7/7/19, Ampicillin 7/27/19 to 7/31/19) for treatment of UTI and the resident's August 2019 MAR documented the resident received 2 antibiotics (Ampicillin by mouth, 8/1/19 to 8/2/19, and Ertapenem (Ivanz) administered intravenously (IV), 8/17/19 thru 8/19/19) for treatment of UTI. Review of the medical record revealed Resident #14 was treated for a UTI in November 2019. On 11/18/19, in a progress note, the physician wrote that Resident #14's diagnosis included UTI associated with catherization or urinary tract and wrote the resident's urine culture was positive, start antibiotic. Review of the resident's physician orders revealed a 11/18/19 order for Bactrim DS (antibiotic) by mouth twice a day for 7 days. Review of Resident #14's December 2019 MAR a 11/30/19 order Ceftin (Cefuroxime) (antibiotic) by mouth twice a day for possible UTI until 12/5/19 and was documented as given 12/1/19 to 12/5/19.
Review of Resident #14's medical record revealed the resident was hospitalized in mid-August 2019, where he/she was treated for a UTI and returned to the facility. Review of Resident #14's 8/16/19 hospital discharge summary revealed the resident's diagnosis included suprapubic catheter associated urinary tract infection and neurogenic bladder, status post suprapubic catheter. The physician documented the resident had a history of recurrent UTI's and his/her urine culture was positive for a urinary tract infection that was treated with IV antibiotics, which would be continued when the resident returned to the facility. The physician wrote that Resident #14's catheter needed to be changed per urology (field of medicine that focuses on diseases of the urinary tract) recommendations and the patient needed to follow-up with the urologist (physician who specializes in diseases of the urinary tract) in the next 1-2 weeks following discharge. The medical record also documented that Resident #14 was hospitalized in late November 2019 and returned to the facility. Resident #14's 11/30/19 hospital transfer summary documented diagnosis that included acute kidney injury, rule out UTI, and that the resident was post treatment with antibiotics at the facility and with IV antibiotics at the hospital. The physician documented that the resident was in need of suprapubic catheter replacement in the near future.
Review of Resident #14's quarterly assessment with an ARD (assessment reference date) of 8/18/19 revealed Section I, Active Diagnosis, 12300, Urinary Tract Infection (UTI) (Last 30 days) was blank. There was no other documentation in the MDS to indicate the resident had a UTI in the past 30 days. Review of Resident #14's quarterly assessment with an ARD of 8/28/19, Section I, Active Diagnosis, 12300, Urinary Tract Infection (UTI) (Last 30 days) was blank. There was no other documentation in the MDS to indicate the resident had a UTI in the past 30 days. Both of Resident #14's quarterly assessments (ARD 8/18/19 and 8/28/19) failed to document that Resident #14 had a UTI in the past 30 days.
Continued review of Resident #14's medical record failed to reveal documentation that Resident #14's suprapubic catheter had been changed in August, September, October or November 2019 and there was no documentation found to indicate the resident had followed-up with a urologist.
Review of Resident #14's August 2019 Treatment Administration Record (TAR) revealed an 7/25/19 order, discontinued (d/c) on 8/15/19, change suprapubic cath when occluded, leaking or to obtain urine specimen as needed, which was not documented as being done in August 2019. The order failed to indicate a catheter size. There was a 7/25/19 order, d/c 8/15/19, to change suprapubic cath when occluded, leaking or to obtain urine specimen every evening shift every 1 month staring on the last day of the month for 28 days, which was documented as being done every evening shift for 14 days (8/1/19 thru 8/14/19). However, further review of the medical record failed to substantiate that the resident's suprapubic catheter was changed on those dates. The order failed to indicate a catheter size. There was an 8/16/19 order change Foley (thin, sterile tube inserted into the bladder) catheter when occluded, leaking or to obtain urine specimen as needed that was not documented as being done in August 2019. The order did not indicate the catheter size or that the resident's catheter site was suprapubic. There was an 8/17/19 order, Foley 24 Fr (French) (size) 10 cc (cubic centimeter) (amount of fluid) balloon (holds catheter in place in the bladder) for diagnosis/need to change, notify MD when Foley catheter occluded or leaking, in the evening starting on the 17th and ending on the 17th every month for infection prevention that was not documented as being done on the 17th and did not indicate the resident's catheter site was suprapubic.
Review of Resident #14's September 2019 TAR revealed an order change Foley catheter when occluded, leaking or to obtain urine specimen as needed that was not signed off as being done in September 2019. The order did not indicate it was for a suprapubic catheter or the catheter size. On the TAR was an order Foley 24 Fr 10 cc balloon for diagnosis/need to change, notify MD when Foley catheter occluded or leaking, in the evening starting on the 17th and ending on the 17th every month for infection prevention which was discontinued on 9/6/19. The order did not indicate it was for a suprapubic catheter change. There was a 9/6/19 order for S/P (suprapubic) catheter 24 FR with 10 cc balloon to bedside straight drainage for diagnosis/HX (history) of need change. Notify MD when Foley catheter occluded or leaking every shift for infection prevention every shift. The order did not indicate the staff were to change the catheter. There was no other documentation on the TAR to indicate Resident #14's suprapubic catheter was changed in September 2019.
Review of Resident #14's October 2019 TAR revealed an order change Foley catheter when occluded, leaking or to obtain urine specimen as needed that was not documented as being done. The order did not indicate a suprapubic catheter change or the catheter size. No other orders to change the resident's catheter were identified on the October 2019 TAR.
Review of Resident #14's November 2019 TAR revealed an 8/16/19 order change Foley catheter when occluded, leaking or to obtain urine specimen as needed that was not documented as being done in November 2019. The order, discontinued on 11/30/19, failed to indicate the catheter size or that it was a suprapubic catheter. There was a 11/30/19 order to change suprapubic tube every month and PRN (as needed) by Urology (when occluded, leaking or to obtain urine specimen), that was not signed off as being done in November 2019. The order did not identify the size of the catheter and indicated that Urology would change the resident's suprapubic catheter when it needed to be changed. There were no other orders to change the Resident #14's s/p catheter seen in the November 2019 TAR.
Review of Resident #14's December 2019 TAR revealed an 11/30/19 order to change suprapubic tube every month and PRN (as needed) by Urology (when occluded, leaking or to obtain urine specimen) that did not indicate the size of the catheter. The order indicated that, when needed, the catheter would be changed by urology. The order was documented as being done on 11/3/19 at 11:40 PM and indicated that the catheter was changed by the nurse at the facility. No further documentation was found in the medical record to indicate the resident's catheter had been changed by urology.
Review of Resident #14's care plans revealed a care plan, initiated on 4/4/19, Resident requires a supra-pubic cath r/t neurogenic bladder with the goal Resident will have no signs and symptoms of urinary tract infection x 90 days, which was initiated on 4/4/19, revised on 5/31/19 and had a target date of 11/29/19. Continuous review of the medical record failed to reveal evidence the care plan had been reviewed after resident's quarterly assessment with an ARD of 8/18/19 or after the resident's quarterly assessment with an ARD of 8/28/19. On 9/6/19 at 10:04 AM, in a care plan evaluation note, the nurse documented that the care plan was reviewed and updated. The nurse wrote that the resident continued to require the suprapubic catheter and continued cranberry tablets for preventative maintenance and to continue with the plan of care and interventions. The care plan evaluation did not measure the residents progress or lack of progress toward reaching his/her goals and did not reflect that the facility reassessed the effectiveness of the approaches. There was no evidence that the care plan had been updated based on the needs of the resident or in response to current interventions.
Continued review of Resident #14's care plans revealed a care plan, Resident is at risk for UTI r/t chronic S/P (suprapubic)use d/t (do to) neurogenic bladder with the goal Resident's UTI will be resolved s/p (status post) po (by mouth) ABT (antibiotic) therapy. The date initiated was 3/18/19 for the care plan focus, goal and interventions with a goal revision date of 9/19/19. There was no evidence in the medical record that the care plan had been evaluated following the resident's quarterly assessments with an ARD of 8/18/19 and an ARD of 8/28/19. On 9/6/19 at 9:54 AM, in a care plan evaluation note, the nurse documented that the care plan had been reviewed and updated, that the resident continued to be high risk for UTI's related to the suprapubic catheter and to continue with POC and interventions. There was no evidence that the care plan goal had been evaluated for the resident's progress or lack of progress towards his/her goal or if the goal continued to be appropriate and failed to reveal evidence the care plan had been updated based on the needs of the resident or in response to current interventions.
The Director of Nurses and Corporate Nurse were made aware of the above findings on 12/6/19 at 2:29 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews and observations it was determined that the facility failed 1a) to ensure the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews and observations it was determined that the facility failed 1a) to ensure the resident's nutritional needs were re-evaluated when a supplement order expired for a resident with pressure ulcers b) to ensure eating assistance was provided as indicated in a resident's care plan; c) that nursing staff provided g-tube feedings as ordered; and 2) failed to ensure recommendations for needed supplements were communicated to the dietary staff in a manner in which ensured supplements were provided on a regular basis. This was found to be evident for 2 out of 10 resident's reviewed for pressure ulcers (Resident #110 and #27).
The findings include:
1) On [DATE] review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive, chronic kidney disease, high blood pressure, diabetes and lung disease. The resident has had a g-tube since 2018 although the resident does consume meals by mouth. Review of the [DATE] minimum data set assessment revealed the resident requires extensive assist from staff for eating. The resident's weight in [DATE] ranged from 124.8 - 130.4 lbs. In [DATE] the resident developed a pressure ulcer on the ankle. In [DATE] the resident developed a sacral pressure ulcer.
Review of the medical record revealed that from [DATE] until [DATE] the resident's g-tube feeding order was for 80 cc Jevity 1.5 after meals.
On [DATE] the resident's weight was 128.9 lbs.
a) On [DATE] there was an order for Protein Liquid two times a day for wounds until [DATE], give 30 cc Proheal via mouth with breakfast and lunch. Review of the Medication Administration Record (MAR) revealed documentation that the supplement was administered as ordered from 9/9 thru [DATE].
Review of the medical record revealed the resident was seen by the Registered Dietician (RD #17) on [DATE]. Review of the note from this visit revealed average oral intake was 50 - 75% with assistance by staff. The note also documented the presence of pressure ulcers: Sacrum stage 1 and left ankle unstageable; and that the resident has increased nutrition needs for PU [pressure ulcer] healing. The note revealed the resident was currently receiving the Proheal 30 ml two times a day and Jevity 1.5 [1.5 calories per ml] 80 ml via the feeding tube after meals three times a day. The RD's recommendations included to continue regular liberalized puree diet, assist with PO [by mouth] intake; continue tube feeding as ordered; and continue Proheal 30 ml two times a day for wound healing.
Further review of the medical record failed to reveal an RD re-assessment on [DATE] when the order for the protein supplement stopped.
During an interview on [DATE] at 2:23 PM with RD #17, she reported she did not think she wrote the protein supplement order and did not recall if she was aware that it was only for 30 days. The RD went on to report that the protein supplement did not add that many calories [in regard to weight loss] but confirmed it was a significant amount of protein.
The protein supplement provided an additional 30 gms of protein and 200 calories to the resident's diet per day.
Further review of the [DATE] wound NP #20 note revealed: on tube feeding and supplements. Further review of the medical record failed to reveal any documentation that the resident received, or had current orders for, a nutritional supplement after the protein supplement order expired on [DATE]. From 10/13 thru 10/24 the resident did not receive any protein supplement or increase in g-tube feeding.
On [DATE] the resident's weight was recorded as 114 lbs indicating a significant weight loss. On [DATE] the resident's weight was 114.4 lbs. On [DATE] RD #17 completed a weight change progress note which addressed the significant weight loss of 11.2 % x 30 day; 9.4% loss in 90 days and 14.6% loss over 180 days. PO [by mouth] intake varies at meals, needs assistance, on average 50% intake notes Resident has increased nutrition needs for wound healing. The RD recommended increasing the tube feeding to 1 can (237 ml) Jevity 1.5 after each meal. A corresponding order, dated [DATE], for the 1 can of Jevity after meals was found in the medical record. The RD also recommended weekly weights times 4 weeks.
On [DATE] the wound NP #20 assessed the resident's wounds. The note for this visit revealed left ankle wound was 1 x 1.2 x 0.1 x 0.1 cm and bit of decline. The sacral wound was 4 x 2.5 x 1.0 cm with heavy drainage Stage 4 and decline.
On [DATE] surveyor reviewed the concern with the RD #17 that the supplement ended and was not re-evaluated, the resident's wound worsened and the resident experienced a significant weight loss.
b) On [DATE] review of the medical record revealed a physician order, originally written [DATE], for 100% supervision with all PO intake with meals. Further review of the GNA documentation revealed the coding for documentation for Eating -Self performance as follows: 0- Independent - no help or staff oversight at any time; 1 - Supervision- Oversight, encouragement or cueing; 2 - Limited Assistance - Resident highly involved in activity, staff provided guided maneuvering of limbs or other non-weight-bearing assistance; 3-Extensive Assistance - Resident involved in activity, staff provide weight -bearing support or 4 - Total Dependence - Full staff performance.
Further review of the resident's care plan revealed an intervention of assist with PO [by mouth] intake was added on [DATE]. Review of the Geriatric Nursing Assistant (GNA) documentation for meals revealed staff documented set up help but that the resident wasindependent -no help or staff oversight at any time with eating for 18 out of 36 meals from [DATE] thru the 30th, 2019. Staff documented the resident as being totally dependant for eating for the other half of the meals provided during this time period. Review of the GNA documentation for assistance provided with meals for October and [DATE] also documented the resident as independent for more than half the meals provided to the resident.
On [DATE] at 4:07 PM surveyor reviewed the concern with the Director of Nursing (DON) that GNA documentation from past 30 days revealed staff documenting resident as independent with meals on many occasions, rather than as providing supervision as per physician order, or assistance as indicated in the care plan.
c) Further review of the medical record revealed an order, dated [DATE], for 1 can Jevity 1.5 (237 ml) via PEG [g-tube] to be given after meals at 10:00 AM; 2:00 PM and 7:00 PM.
One can of Jevity 1.5 provides 15.1 gms of protein and 355 calories. Three cans of Jevity 1.5 per day would provide more than 1000 calories and 45 gms of protein per day. According to the [DATE] RD assessment note the resident required 1814 calories per day with 78 gms of protein.
On [DATE] at 9:48 AM surveyor observed an unopened container of Jevity on the resident's overbed table. On [DATE] at 11:04 AM the unit nurse manager #8 observed the Jevity container with the surveyor. The nurse manager reported it had been opened but was not empty at this time and proceeded to throw out the container.
On [DATE] at approximately 2:45 PM review of the medical record revealed documentation that Nurse #40 had administered the Jevity on [DATE].
On [DATE] at 3:04 PM Nurse #40, who had been assigned to care for the resident during the day shift, reported the resident was a feeder [a resident in need of assistance with eating]. When asked if the resident received all nutrition by mouth, the nurse reported: yes. The nurse went on to report if the resident doesn't eat up to 50% he would give the resident a bolus [can of feeding via g-tube]. He confirmed that he had not administered any Jevity today, stating the resident has been going over [the 50%] for eating.
When surveyor reviewed with Nurse #40 that the medical record revealed that the resident is to receive one can of Jevity after meals and that he had documented the administration of the Jevity the nurse reported that he would have to strike it because the resident ate and he did not give the Jevity. He confirmed that he did not administer the Jevity in the morning either. On [DATE] at 3:09 PM the nurse was observed reviewing the orders in the electronic health record and stated looks like they changed the order, how they had [him/her] was if [he/she] eats over a certain amount we don't give the bolus, when I work with [the resident] that is how it's been. The nurse went on to report that he is employed by an agency and usually works on this unit or the rehab unit.
On [DATE] at 3:28 PM surveyor reviewed the concern with the DON regarding Nurse #40's documentation that the Jevity had been administered despite his report that the resident does not receive the Jevity unless the resident eats less than 50% of meals and confirmation that he had not administered the Jevity today.
Further review of the Treatment Administration Record (TAR) and the nursing notes revealed that Nurse #40 documented that the [DATE] Jevity was administered at 10:00 AM. The dose due at 2:00 PM was documented as being held [not given]. The corresponding nursing note with an effective date of [DATE] at 3:09 PM revealed a notation that the resident eat over 50% of [his/her] meal.
Further review of the medical record revealed that from [DATE] until changed on [DATE] the resident's g-tube feeding orders were: after meals give 1 can Jevity bolus if PO [by mouth] intake is less than 50%. On [DATE] the order was changed to 80 cc of the Jevity after each meal and did not include any instructions to hold the Jevity if the resident ate a certain percentage.
Further review of the medical record revealed Nurse #40 had documented having provided the Jevity 1.5 on [DATE] at 10 am and 2 PM. Review of the TARs revealed Nurse #40 had been assigned to Resident #110 on four occasions in [DATE] and two occasions in [DATE].
On [DATE] the resident's weight was recorded as 132.6 lbs. This represents a gain of more than 15 lbs in less than 2 weeks. No documentation of a re-weight was found in the medical record. On [DATE] at 8:19 AM RD #17 reported that staff was suppose to get a re-weight if greater than 5 lb change either way. The next recorded weight was on [DATE] and was 113.4 lbs.
The resident's weight on [DATE] and [DATE] was 112 lbs.
2) On [DATE] review of Resident #27's medical record revealed the presence of a pressure ulcer. Review of the [DATE] registered dietitian's (RD) note revealed the resident was to receive a supplemental pudding at lunch and dinner.
On [DATE] at 1:05 PM observation of the resident's lunch tray failed to reveal the presence of a pudding. This observation was confirmed by GNA #34.
On [DATE] at 8:15 AM RD #17 reported that the resident has a wound and for that the resident is receiving pudding twice a day with lunch and dinner. RD confirmed the pudding is in addition to dessert. The RD went on to report that she added the pudding to the care plan and put it in the meal tracker as a special request so that it prints out on each meal ticket.
On [DATE] at 8:27 AM the dietary manager #1 reported that items under special request are for something extra if they happen to have it. He went on to report if the item is required it should go under notes or snacks. Surveyor reviewed the concern with the dietary manager that according to the RD the pudding should be served with each lunch and dinner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview it was determined that the facility failed to provide hemodialysis (dialysis) services in accordance with professional standards of quality for a resi...
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Based on observation, record review and interview it was determined that the facility failed to provide hemodialysis (dialysis) services in accordance with professional standards of quality for a resident by failing to: 1) have a physician's order for Midodrine that staff could follow, and 2) to properly assess the resident prior to administration of the Midodrine. This was evident for 1 of 1 resident (Resident #114) reviewed for dialysis services.
The findings included:
Hemodialysis - kidneys perform several critical functions. They clean your blood and support important bodily functions. When kidneys cannot perform these functions, hemodialysis may be required. You are hooked up to a machine through an access port directly in the vein and the machine does the work of the kidneys. Sometimes a person may experience low blood pressure during hemodialysis. (https://www.cdc.gov/dialysis/patient/index.html )
During an observation of Resident #114 receiving a dialysis treatment on 11/19/19 at 1:04 PM, Staff #46, revealed that the resident has a tendency to have low blood pressure during dialysis and the resident was supposed to get a medication prior to dialysis treatment and that it did not always happen. She stated I have to ask the nurse to give it to him/her on most days.
A medical record review for Resident #114 on 11/19/19, revealed a history and physical documented by the resident's attending physician #45 dated 10/22/19. He documented the resident had End Stage Renal Disease (ESRD) and had been on dialysis for 3 years. No indication that this resident had experienced low blood pressure during dialysis. Subsequent visit or record reviews by attending physician #45 on 10/23/19, 10/25/19, 10/28/19, 10/31/19, 11/4/19, 11/6/19, 11/11/19, 11/14/19, 11/18/19, 11/21/19, did not document the low blood pressure during or after dialysis.
On 10/24/19, a clinician visit documented by Certified Registered Nurse Practitioner (CRNP) #21 revealed no documentation that this resident has low blood pressure during and after dialysis. Subsequent visits or chart reviews made by CRNP #21 on 10/26/19, 10/29/19, and 11/5/19, did not document the issue either.
On 11/1/19, Resident #114 was seen by CRNP #35 and there was no documentation that the resident had low blood pressure during and after dialysis. However, on 11/7/19, she documented Midodrine as needed for hypotension and on 11/14/19, she documented, continue Midodrine as needed for hypotension (low blood pressure) in hemodialysis.
Review of the physician's order summary dated 10/1/19 - 11/30/19, revealed an order written 10/29/19, by CRNP #21 Midodrine HCL 10 mg (milligram) tablet, Give 1 tablet by mouth every 8 hours as needed for hypotension (low blood pressure), BP (blood pressure) < (less than) 90 systolic (top blood pressure number) and give before dialysis times on HD (hemodialysis) days. There was no order for blood pressure monitoring for this order.
Review of the Medication Administration Record (MAR), revealed that on 11/1/19 at 8:30 AM and 11:12 PM, the Midodrine was given and no blood pressure was documented at time of administration. On 11/7/19 at 8:06 AM, 11/12/19 at 6:25 AM, 11/14/19 at 6:00 AM, 11/18/19 at 6:30 AM, the Midodrine was administered with no corresponding documentation of the blood pressure.
Review of the Concerta Renal Services communication forms for each dialysis day revealed incomplete documentation. On 11/1/19, there was no time for post treatment blood pressure of 93/48. On 11/8/19, the before treatment blood pressure was 95/53 and it was not taken after the treatment was completed. On 11/14/19 at 6:00 AM, Midodrine was administered, however on the communication form the blood pressure at 5:45 AM the blood pressure was 95/69 which was outside the parameters of the orders to give if less than 90 systolic (top blood pressure number).
On 11/13/19, the resident's blood pressure was taken at 9:16 PM and it was 81/54, however the Midodrine was not administered.
During an interview with the Director of Nursing (DON) on 11/19/19 at 1:28 PM, she revealed that she would have expected an order to take the blood pressure daily to determine if the PRN (as needed) medication was needed.
On 11/19/19 at 1:38 PM, during an interview with CRNP #21, she stated that the resident had issue with low blood pressure during and after dialysis. When asked how an agency nurse would know to give the medication on dialysis days she responded they get that information in report (referring a verbal report between the nurses at shift change). She stated that she did not indicate specific times to give the midodrine because the resident's dialysis schedule may change. Informed her that the MAR indicated that the resident was not receiving the medication every time she had dialysis and the CRNP stated the resident may not have needed it on those days, however the order stated to give on dialysis days with no parameters given. She stated to this surveyor to check with nursing because she was sure they can see the order in the electronic Medication Administration Record (eMAR).
On 11/19/19 at 2:49 pm, during an interview with RN #50, reported she was not aware that Resident #114 was to receive Midodrine before dialysis. She showed the surveyor on her computer the view she had in the eMAR which was when a resident was due for a routine medication that medication turned green and when it was overdue it turned red. However, an as needed order, such as the Midodrine, was under another tab and did not indicate if a resident was due because it was as needed and not routine. She reported that this was the first time she had been assigned Resident #114 and was not told in report about the Midodrine being given before dialysis.
During an interview with Assistant Director of Nursing (ADON) on 11/19/19 at 3:04 PM, revealed she agreed that this order was not written in a way that staff would be aware to give before dialysis. It was reported to her the conversation with the agency nurse and the ADON was also made aware that the blood pressures were not documented each day the resident received the medication. The ADON reported that there was a communication book for dialysis and reviewed with Surveyor that the nurse was to complete vital signs on the day of dialysis and write them in the book. She stated the dialysis staff complete the post treatment portion of the form. She stated her expectation of staff to give the Midodrine after they take the blood pressure and not to rely on dialysis staff to tell them the blood pressure.
The DON was made aware of the concerns on 11/21/19 at 3:31PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on review of employee files and staff interview it was determined that the facility staff failed to put a system in place to ensure new hire Geriatric Nursing Assistant's (GNA's) were competent ...
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Based on review of employee files and staff interview it was determined that the facility staff failed to put a system in place to ensure new hire Geriatric Nursing Assistant's (GNA's) were competent with their skills sets. This was found to be true for 3 of 6 new hire employees (Staff #54, #55, and #56) reviewed for competencies and skill sets. This deficient practice has the potential to affect all residents in the facility.
Findings include:
On 11/21/19 at 2:15 PM a review of new hire employee files was conducted. Review of the new employee records for GNA #54, #55, and #56 revealed that there was no documentation found that indicated the GNA's had completed their competency skills and techniques to safely provide care to the residents.
On 11/22/19 at 10:36 AM in an interview with the Nurse Practice Educator regarding the skills assessments missing in GNA #54, #55, and #56's employee files was conducted, he stated the GNA's are assigned to a mentor for skills that are not covered in the classroom and that the GNA's mentor is responsible to complete the competency skills lists and return it to the Nurse Practice Educator. The sheets must be completed before the GNA can work independently with residents. He continued to say that not all the forms make it back to him from the mentors and he would attempt to retrieve them from the mentors.
However, on 11/25/19 at 9:51 AM in an interview, the Nurse Practice Educator stated he was unable to locate the GNA's missing skills assessments and confirmed the surveyor's concerns.
The Administrator, Staff #3 and Director of Nursing were made aware of the surveyor's findings during the exit interview 12/11/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on medical record review, interview and observation it was determined that the facility failed to ensure a medication error rate below 5% as evidenced by 3 errors out of 30 opportunities for err...
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Based on medical record review, interview and observation it was determined that the facility failed to ensure a medication error rate below 5% as evidenced by 3 errors out of 30 opportunities for error during the medication pass observation task evidenced by failure to administer as needed pain medication when requested due to nurse not having access to the electronic health record, failure to administer a medication due prior to breakfast due to delay resulting from nurse not having access to the electronic health record, and failure to administer a medication when due because the nurse did not recognize the name of the medication as one of the medications that was available on the medication cart. This was found to affect 2 out of the 4 residents observed (Resident #47 and #117) during the medication observation task.
The findings include:
On 11/19/19 at 8:19 AM Nurse #66 reported she works for an agency and that she would be administering medications once she was able to get access to the [electronic health record (EHR)] system. At 8:20 AM Resident #47 was observed in the hallway requesting pain medication from Nurse #66.
The unit nurse manager #5 confirmed this was Nurse #66's first day at the facility. Review of the posted staffing revealed Nurse #66 was assigned to care for Resident #47. At 8:26 AM Nurse #66 was observed on the phone. At 8:40 Nurse #66 remained on the phone, she confirmed she still did not have access to the EHR. The nurse went on to report that she arrived at 7:00 AM, at 7:45 AM she was informed that she would have EHR access in 15 minutes. At 8:58 AM Nurse #66 was unable to gain access to the EHR. At 9:00 AM Resident #47 reported he would be going downstairs but would be back. At 9:04 AM Nurse #66 was again on the phone attempting to get EHR access.
On 11/19/19 at 9:11 AM Nurse #66 reports she now had EHR access and began preparing medications for Resident #11.
During the observation of Resident #11's medication administration, at 9:19 AM Resident #117 approached Nurse #66 requesting his/her medications. Resident #117 informed the nurse that breakfast was already here and the medication was suppose to be taken before eating. The nurse acknowledged the resident's request and the resident returned to his/her room. At 9:29 AM Resident #47 had returned to the unit and was waiting by the medication cart requesting pain medication.
Prior to preparing and administering Resident #47's pain medication the unit nurse manager moved the resident to the shower room. Nursing staff obtained the resident's blood pressure prior to preparing the resident's morning medications. At 9:37 AM Nurse #66 was observed preparing the resident's medications, the resident had reported the pain level to be a level 9. The nurse was observed administering the 3 other medications along with the pain medication.
Review of the Medication Administration Record revealed the pain medication, which had been requested as early as 8:20 AM was administered at 9:45 AM to Resident #47.
On 11/19/19 at 9:50 AM the Director of Nursing (DON) reported that she is responsible for ensuring newly arrived agency staff have access to the EHR. She went on to report that she had been on the unit earlier and denied that she had been informed that the nurse did not have access, stating she can obtain access in 15 minutes. Surveyor then reviewed the observation, with the DON and the Administrator of the nurse not having access to the EHR for an hour and the delay in the administration of pain medication which was reported at a level 9 by the time the medication was administered to Resident #47.
On 11/19/19 at 10:34 AM surveyor observe Nurse #66 preparing Resident #117's medication. The nurse confirmed she was preparing the medications that had been due at 8:00 AM. The nurse prepared 10 pills total. Prior to taking the pills the resident poured them out and counted the 10 pills out. The resident expressed concern regarding the sulcralfate which had been due prior to breakfast. The nurse informed the resident that this was the dose that was due at 11 AM, prior to lunch.
After the medication pass observation surveyor reviewed the orders and the Medication Administration Record. An order was found for Sucralfate to be given before meals and at bedtime for ulcers.
On 11/19/19 at 11:07 AM review of the medical record revealed an order for Tadalafil 20 mg give 2 tablet by mouth one time a day for pulmonary hypertension. Tadalafil was not one of the medications observed as having been administered. Review of the MAR revealed the nurse had documented that the 9:00 AM dose of Tadalafil had been administered.
On 11/19/19 at 11:14 AM Nurse #66 confirmed the Tadalafil had not been administered. She reported that she wrote the medication down because it was not available but also confirmed that she had documented that it had been administered and stated she needed to go check if it was available. The unit nurse manager #5 was called over by the nurse at this time. The unit nurse manager identified a med card with a medication named Alyq 20 mg as the Tadalafil. The Nurse #66 checked to make sure these were the same medications, stating this is not the name of the medication in the [electronic health record]. The nurse then prepared and administered the two 20 mg tablets.
On 11/21/19 at 3:02 PM surveyor reviewed the three observed errors with the unit nurse manager #5: the missed medication that was due prior to breakfast; the medication that was not administered but staff had documented that it was administered, and the pain medication that was delayed in being administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
2) Resident #13's medical record was reviewed on 11/19/19 at 10:09 AM. Review of Resident #13's physician's orders revealed a 10/17/19 order for the resident to have his/her stool tested for occult bl...
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2) Resident #13's medical record was reviewed on 11/19/19 at 10:09 AM. Review of Resident #13's physician's orders revealed a 10/17/19 order for the resident to have his/her stool tested for occult blood (blood in feces that is not visibly apparent). Continued review of the paper medical record and the electronic medical record (EMR) failed to reveal evidence that the lab test had been completed.
On 11/20/19, during an interview, Staff #4, RN, confirmed that the lab test had not been completed. Staff #4 stated that when the order was entered in the resident's TAR (treatment administration record), it did not include a schedule, which would have identified when the lab was to be obtained.
Based on medical record review and staff interview it was determined that the facility failed to perform laboratory blood testing as prescribed. This is noted for 1 of 5 residents (Resident #104) reviewed for unnecessary medications and 1 of 8 residents (Resident #13) reviewed for hospitalization.
The findings include.
A doctor analyzes the laboratory blood test to see if results fall within the normal range. The doctor may also compare the results to results from previous tests. Laboratory tests are often part of a routine checkup to look for changes in patient health. They also help doctors diagnose medical conditions, plan or evaluate treatments, and monitor diseases.
1) Review of Resident #104's medical record on 11/19/19 revealed a standing order for a laboratory blood test to be performed every 6 months for valproic acid (trough) and Liver function test that was originally ordered on 3/10/19. Both test were scheduled for 9/1/19 on the September 2019 treatment administration record. The test was not performed on 9/1/19. The signature/initials on the treatment record for 9/1/19 indicated ZZ (in progress).
A pharmacy consult dated 10/4/19 indicated not finding the prescribed laboratory blood test. The Unit manager was notified on 11/21/19 at 11:00 AM of not locating the prescribed blood work in the resident's chart. The Director of Nursing was informed on 11/22/19 at 3:45 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a physici...
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Based on observation, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a physician's dental consult request. This was evident for 1 of 3 residents (Resident #32) reviewed for dental.
The findings include:
On 11/18/19 at 11:54 AM, Resident #32 was observed to not have upper teeth. At that time, during an interview, Resident #32 stated he/she did not have any upper teeth or upper dentures and wanted to see a dentist. Resident #32 stated that the dentist comes in once a month, however the resident had not seen the dentist. Resident #32 stated that the staff kept telling him/her that the resident was on the list to see the dentist, however he/she's been on the list for a while.
On 11/25/19 at 12:18 PM, review Resident #32's medical record revealed a 10/22/18 physician order that included Dental Consult and treatment as needed for patient health and comfort. Further review of the medical record revealed an Attending Physician Request for Services/Consultation form, dated 7/22/19, that requested a dental consult for Resident #32. Continued review of the medical record failed to reveal evidence that the physician's request for Resident #32 to receive dental services had been acted upon. There was no documentation in the medical record to indicate Resident #32 had been seen by a dentist.
On 11/25/19, at 1:22 PM, during an interview, the Director of Nurses (DON) was made aware of the above finding. When asked what the process was for obtaining a dental consult, the DON stated that when the physician or nurse practitioner orders the consult, the unit clerk faxes the consult to the service provider, the resident's name is added to the dental list and then the resident is seen by the dentist every so often. The DON indicated that he/she was unsure how often the dentist saw residents in the facility. On 11/26/19, the DON provided the surveyor with an Attending Physician Request for Services/Consultation form, dated 11/25/19, that requested a dental consult for Resident #32. The form was accompanied with a letter dated 11/25/19 that stated the facility would be financially responsible for a one-time dental consultation for Resident #32. When asked what the reason for the delay was in obtaining dental services for Resident #32, the DON stated it was because of the insurance, and that the facility is required to send a letter with each consult request.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility records and interview with staff, the facility failed to conduct and document an accurate facility-w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility records and interview with staff, the facility failed to conduct and document an accurate facility-wide assessment that included hospice residents. This was evident during the extended survey task conducted during the annual survey and has the has the potential to affect all residents within the facility.
The findings include:
A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population.
Review of the facility-wide assessment dated [DATE] revealed the facility staff documented there were 0 residents receiving hospice care.
During interview on 12/9/19 at 11:15 AM with the Administrator, she stated on 10/23/19 there were 2 residents receiving hospice care (Resident #13 and #27).
Interview with the Administrator, Staff #3 on 12/9/19 at 11:15 AM confirmed the facility staff documented an inaccurate facility-wide assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) A record review for Resident #99 on 11/15/19 at 11:00 AM, revealed a physicians' order summary for October 2019 and November ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) A record review for Resident #99 on 11/15/19 at 11:00 AM, revealed a physicians' order summary for October 2019 and November 2019 that documented an order for abacavir-dolutegravir-lamivud 600-50-300 mg (Triumeq) give 1 tablet by mouth 1 time a day for Human Immunodeficiency Virus (HIV).
On 11/20/19 at 11:17 AM, review of the facility's pharmacy receipt log for 10/2019 and 11/2019, revealed that the Triumeq was not dispensed to the facility until 11/13/19. In addition, review of facility's medication list available in the drug storage box revealed that the Triumeq was not kept on hand in the facility.
Review of the Medication Administration Record (MAR) for October 2019, revealed that over a 9 day period (10/23/19 - 10/31/19) the Triumeq was not available to give to the resident and 4 nurses cared for him/her during this time and there was no documentation in the MAR or progress notes that the physician was made aware.
In addition, review of the physician's progress notes dated 10/23/19 and signed by Certified Registered Nurse Practitioner (CRNP) #21, progress note dated 10/24/19 signed by attending Physician #44, and 10/25/19 note signed by CRNP #35 revealed documentation that they thought the resident was receiving the Triumeq as ordered.
Review of the MAR for November 2019, revealed that over a 12 day period (11/1/19 - 11/12/19) that Triumeq was not available to give to the resident and 7 nurses had cared for him/her during this time and there was no documentation in the MAR or progress notes that indicated the physician was made aware.
The Director of Nursing (DON) was interviewed on 11/20/19 at 2:29 PM, and she stated the first time she heard about the missing medication was on 11/10/19, when Resident #99 informed her about the missing medication. She reported that she signed the pharmacy form and sent it to the pharmacy and the medication was received a few days later. She stated that she did not investigate the issue, assess the resident, or call the physician. She stated I should have.
During an interview with Licensed Practical Nurse (LPN) #6 on 11/21/19 at 2:33 PM, revealed she didn't notify the physician every time a medication was missing, but attempted to resolve it with the pharmacy first. However, on 10/27/19 and 10/31/19, she was assigned to the resident and marked the medication as being given when it was not available and no indication the physician or CRNPs were notified.
On 11/22/19 at 10:20 AM, an interview with attending Physician #44, via phone call, revealed he does not recall being made aware of the medication not being available for the resident until surveyor intervention on 11/21/19.
On 11/21/19 at 11:36 AM, the Director of Nursing, Administrator (Staff #2) and Administrator (Staff #3) were informed of the concerns. (Cross Reference: F658, F684, F755, F760, and F842)
3) Resident #58's medical record was reviewed on 12/5/19 at 9:35 AM. The resident was admitted [DATE].
The resident's weights were recorded in his/her electronic medical record as:
10/2/19 - 162.8 (total lift)
10/7/19 - 160.6 (total lift)
10/24/19 - 144.4 (total lift)
10/25/19 - 155.5 (wheelchair)
11/5/19 - 150.2 (wheelchair)
11/13/19 - 141.0 (wheelchair)
11/18/19 - 137.2 (wheelchair)
11/19/19 - 137.2 (wheelchair)
11/26/19 - 139.8 (wheelchair)
12/3/19 - 142.4 (wheelchair)
Each weight from 10/24/19 through 12/3/19 included a warning related to the residents weight change. Weight loss greater than 5% in 1 month, 7.5% in 3 months or 10% in 6 months is considered a significant loss.
Resident #58's record reflected that he/she experienced a significant weight loss of 7.74% (12.6 lbs.[pounds]) over the 1 month period from 10/2/19 to 11/5/19. Resident #58's weight continued to decrease until 11/26/19. His/her lowest weight was 137.2 lbs. recorded on 11/18/19. This reflected a 15.72% (25.6 lb.) loss in the 47 days (approximately 1 and ½ months) from his/her admission to the facility. Resident #58 then gained 5.2 pounds over the next 15 days to a weight of 142.4 lbs. on 12/3/19. This final weight reflected an overall 1 month weight loss from 11/5/19 to 12/3/19 of 5.19% or 7.8 lbs. and total weight loss over 2 months (since admission) of 20.4 lbs. or 12.53%.
In a Nutrition Progress Note dated 11/6/19 the dietician identified that the resident had a significant weight loss of 7.7% over 30 days, the dietician and resident discussed food choices, the resident's family brought food in every other day and the resident bought items from the vending machine. The Dietician indicated that the resident's food preferences were updated. Another Nutrition Progress Note dated 11/13/19 noted the resident's continued weight loss of 6.1% in 1 week (12.2% over 30 days). It reflected that the resident voiced a dislike for the facility food, denied difficulty eating and was happy to have lost weight. The Dietician noted that she counseled the resident about gradual weight loss as opposed to significant weight loss. The notes did not indicate that the physician was aware of Resident #58's significant weight loss.
The record contained 22 physician's progress notes and 4 Certified Registered Nurse Practitioner (CRNP) progress notes written between 10/2/19 and 12/2/19. Every progress note stated: Appetite satisfactory. No significant weight change.
The physician progress notes included the resident's weight measurements. The 14 physicians progress notes written between 10/24/19 to 12/2/19 included a warning indicating there was a weight change, the percentage of the weight change and the word False. There was no evidence that the physician was aware of nor addressed the resident's significant weight changes. There was no documentation in the record to indicate that the physician or the CRNP were notified of and evaluated Resident #58 when he/she had an initial and ongoing significant weight changes.
Further review of the record revealed a care plan for: Resident is at nutritional risk related to multiple medical diagnoses. The interventions on initiated 10/3/19, included but were not limited to Weigh per MD (physician) order and alert dietitian and physician to any significant loss or gain and Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
During an interview on 12/6/19 at 9:51 AM Staff #15, the Unit Manager was asked how staff identified significant weight losses. She indicated the electronic system kicks out if there is a weight change. The Dietician is notified via email or during morning rounds and the physician is notified via email by either herself or the dietician. She was asked if the physician was notified each time Resident #58 had a significant weight loss. Staff #15 was unable to find evidence that the physician had been notified. She then indicated that the surveyor would have to ask the dietician because she would have notified the physician.
Staff #17, the Dietician was interviewed on 12/6/19 at 10:17 AM. She was asked how she and the physician are notified when a resident has a significant weight change. She indicated that she runs her own reports but nursing also notifies her, and that nursing notifies the physician. When asked if she notifies the physician of significant weight changes, the dietician confirmed that she does not and confirmed that she had not notified the physician of Resident #58's weight losses.
The Director of Nursing was made aware of these concerns on 12/6/19 at 11:07 AM.
2A) An interview was conducted with the family member of Resident #136 on 11/21/19 at 9:36 AM who stated that Resident #136 did not receive the medication Suboxone for 2 days, and when you need it you need it.
Review of the medical record for Resident #136 on 11/21/19 revealed the resident was admitted to the facility on [DATE] from an acute care facility. Review of the 8/23/19 hospital discharge summary revealed a list of medications that the resident was prescribed to take while at the facility which included the medication buprenorphine-naloxone (Suboxone) 4 mg - 1 mg sublingual film which was to be taken 2 times per day for narcotic dependence.
Review of Resident #136's August 2019 Medication Administration Record (MAR) revealed nurse's initials with notations that the medication was not given on 8/24/19 at 9 AM, 8/24/19 at 9 PM and 8/25/19 at 9 AM. The resident received the first dose of medication on 8/25/19 at 6 PM. Cross Reference F 755.
Review of the pharmacy controlled substance Prescription (Class II-V) form documented Suboxone was to be given BID (twice per day) and was faxed to the pharmacy on 8/24/19 at 15:22 (3:22 PM). The resident was admitted on [DATE] and the orders were verified with the physician on 8/23/19 at 20:56 (8:56 PM).
A nursing note dated 8/24/19 at 22:40 (10:40 PM) documented, Pharmacy called at 6 pm, they said it would be sent out stat. Still not here at 10 pm. Pharmacy called again. The pharmacist said he would send it stat again. To be given by night nurse when it arrives.
A nursing note dated 8/24/19 at 23:41 (11:41 PM) documented, Patient somewhat upset that suboxone has not been delivered by pharmacy yet. Pharmacy called and will send stat.
A physician's history and physical was done on 8/25/19 at 11:00 AM and documented that the resident feels some withdrawal symptoms now.
An interview was conducted with CRNP (Certified Registered Nurse Practitioner) #21 and CRNP #35 on 11/21/19 at 1:10 PM and they were asked if they expected to be notified after the second and third doses were missed and the response was, yes.
2B) An interview was conducted with the family member of Resident #135 on 12/4/19 at 8:38 AM. The family member stated that the facility was aware that Resident #135 was going to be admitted on [DATE] and the facility did not have the IV (intravenous) antibiotics readily available. Review of the acute care hospital Discharge summary dated [DATE] documented the resident was to take Oxacillin 2 grams IV every 4 hours for 22 days due to an infection.
Review of Resident #135's February 2019 MAR documented that the resident did not receive the Oxacillin until 1300 (1 PM) on 2/2/19. The resident missed the 5 AM and 9 AM doses. RN #64 was the nurse on duty at the time.
Review of the Individual Performance Improvement Plan for RN #64, that was given to the surveyor by the Director of Nursing, documented that on 2/2/19 the RN was assigned to Resident #135 who was admitted on [DATE] and was advised in report that the resident's medications had not arrived. The document stated that RN #64 failed to call the pharmacy to follow-up and that RN #64 did not pull the medications that were available from the Omnicell (interim box). RN #64 failed to notify the physician that the first 2 doses of the antibiotic were missed and failed to get direction from the physician as how to proceed.
The Director of Nursing confirmed the findings on 12/4/19 at 11:30 AM.
Based on medical record review, interview with family and staff, it was determined that the facility failed to: 1) notify the primary care provider that a resident was continuing to smoke cigarettes while receiving the nicotine patch, placing the resident at risk for a nicotine overdose. This was found to be evident for 1 out of 74 residents (Resident #371) reviewed for facility reported incidents; 2) notify the physician that medications were not readily available for a new admission. This was evident for 2 of 15 (Resident #136 and #135) complaints reviewed; 3) to notify the Physician when the resident experienced significant weight loss. This was evident for 1 of 5 residents (Resident #58) reviewed for nutrition 4) notify a resident's attending physician when an ordered medication was not available. This was evident for 1 of 8 residents (Resident #99) reviewed for pharmacy reviews.
The findings include:
1) On 12/11/19 review of Resident #371's medical record revealed the resident had lung disease, high blood pressure and a dependence on nicotine.
Review of the Primary Care Provider (PCP) Nurse Practitioner (NP) #21 note, dated 6/30/19, revealed the following: Educated on the importance of quitting smoking and the dangers of continuing to smoke, including worsening COPD (chronic obstruction pulmonary disease), CAD (coronary artery disease) and risk of stroke. [Resident] is amenable to nicotine patch.
While receiving the nicotine patch an individual should not smoke cigarettes due to a risk of nicotine overdose.
Further review of the medical record revealed an order for a nicotine patch to be applied one time a day starting on 6/30/19. Review of the Medication Administration Record revealed documentation that the patch was applied, as ordered, on 6/30, 7/1, 7/2 and 7/3/2019.
Review of a facility reported incident revealed the resident was found to be smoking in his/her bathroom on 7/1/19 at 12 noon. Per the facility report documentation a behavior contract was established with the resident and the smoking policy was reviewed. A care plan was established, on 7/1/19, with a stated goal of: Patient will smoke safely x 90 days per smoking policy. The following interventions were included in the care plan: Inform and remind patient of location of smoking areas and times; supervise patient with smoking in accordance with assessed needs.
Further review of the medical record failed to reveal documentation that the primary care provider had been informed that the resident had been found smoking and that a care plan to facilitate continued smoking had been established. Review of the facility's Event Summary Report for the 7/1/19 event also failed to reveal documentation that the physician had been notified as evidenced by no being documented in the section Physician Notified.
Further review of the medical record revealed the primary care provider physician saw the resident on 7/1/19 and 7/3/19. The primary care provider NP #21 also saw the resident on 7/2/19. Further review of the progress notes associated with these three visits failed to reveal documentation that either of the PCPs had been informed that the resident was continuing to smoke while receiving the nicotine patch.
On 12/11/19 at 11:15 AM the Director of Nursing, when asked if any education was provided to residents who receive the nicotine patch, responded: we talk to them about not smoking. Surveyor then reviewed the concern regarding the failure to inform the PCP that the resident was continuing to smoke while receiving the nicotine patch.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview it was determined the facility staff failed to have a process to provide house...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview it was determined the facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was evident throughout the survey and on all nursing units.
The findings include:
Environmental observations were made during the survey and compiled for an environmental tour that was conducted with the Maintenance Director (Staff #19) on 12/6/19 beginning at 2:20 PM. The following items were identified during this tour and throughout the survey:
a. Beginning in the first-floor corridor, the three doorways of the kitchen were observed to have various issues with missing molding, exposed uneven rough edges with damaged deteriorating walls where the molding was missing. The molding leading into one of the doorways of the rehab department was busted and cracked. Both rehab entrances were noted with missing molding leaving exposed uneven edges and damaged walls around the door frames.
b. In room [ROOM NUMBER], the approximately 6-inch-wide chair rail along the head of the bed wall was noted to be damaged with chipped, rough and very dirty areas.
c. room [ROOM NUMBER] the door to the toilet room was observed to have worn horizontal stripes across the lower bottom of the wooden door. The veneer was rough and splintered (the horizontal striped holes penetrated the hollow cavity of the door). The wall near the entrance to the room by the hand sanitizer was very dirty.
d. room [ROOM NUMBER], observations of the toilet room revealed splatter like stains on the wall next to toilet and a hole noted in the inside portion of bathroom door.
e. In room [ROOM NUMBER], multiple environmental concerns were originally observed on 11/15/19 at 10:31 AM. The door had a hole in the center below the handle, no mirror but 4 clear plastic holders remained dangling from the door. The interior of the shared toilet room was noted with scraped rough wood along the bottom widths of both doors. The bathroom floor was dirty with a discolored brown stain around the toilet and the lower halves of the bathroom metal door frame were observed with scraped marking with missing paint.
f. In room [ROOM NUMBER], no base board was observed on the bathroom wall across from the toilet. The bottom of wall had a large punch hole approximately 2.5 feet wide x 6 inches tall. The rest of the wall near the floor was scraped up with pieces of wall missing and the floor around the toilet was discolored and brown. The bottom of both interior bathroom doors were scraped with the finish missing.
g. room [ROOM NUMBER], the wide wood bed rail on the wall next to the bed appeared unfinished and noted with rough and splintered areas.
h. In room [ROOM NUMBER], original observations made on 11/18/19 revealed that the wide chair rail was noted with scrapes with splintered and rough wood. The environmental tour on 12/6/19 revealed that the chair rail was removed from the wall leaving behind a great amount of exposed damage to the wall (multiple gaping rough unfinished holes). The Maintenance Director acknowledged removing the wide board off the wall but had been unable to compete the repair. Two stained ceiling tiles in the corner of the wall behind behind the B-bed were also observed. Additionally, there was a missing handle on 1st drawer of B-bed dresser with a loose right handle on the third drawer down.
i. room [ROOM NUMBER], in the left corner of the room there was an area that was approximately 2.5 by 8 feet with paint missing. There was a tan/sand like dust on parts of the wall. There were two stained ceiling tiles above and to the right of the A-bed wardrobe. Behind the free-standing wooden closet/wardrobe approximately 2.5 x 8 feet was a different color paint with multiple holes in a horizontal line across half of that area. Also observed were missing baseboard/cove molding with exposed cinder block on the left interior wall next to the door. Observations in the shared bathroom revealed no base board/cove molding on the wall across from the toilet. On the left wall, there was an observed gap between the wall and floor with debris in the gap. On the inside of the bathroom door there were observed scrapes (finish missing) in the wood veneer across the horizontal width of lower part of door. Bubbled up paint was observed on the wall under the soap dispenser.
j. room [ROOM NUMBER], was observed with an unfinished wall repair of a 1 foot by 1.5 foot cut out in the wall, with replaced non-spackled, non-painted wall board. The wide board rail along the bed against the wall had areas with rough splintered wood, one measuring approximately 2 x 3 inches and the second approximately 4 x 5 inches. There was an unfinished wall with different color paint/wall papered area where a previous closet/wardrobe was located. The bathroom floor was noted dirty and grimy especially behind the toilet. There was noted damage to the interior upper right-hand corner of the bathroom door. There was a doorknob sized hole in the wall opposite of the sink and the door frame was marred on lower halves with evident scrapes of missing paint.
k. room [ROOM NUMBER], the A-bed footboard was observed to be missing laminate on right lower corner and the entire top edge veneer was peeling away. There was missing laminate on the left side of wooden wardrobe drawer, approximately 5 x 7 inches. On the inside of the wooden bathroom door was a 2 x 2 inch hole. The walls in the bathroom had mismatched paint, and one entire ceiling tile was stained brown.
l. room [ROOM NUMBER], observation of multiple small holes noted on left hand side entrance wall under boxed glove holder. Both sides of the room had unpainted and black stained areas from the previous placed wardrobe/wooden closets. Observations in the toilet room revealed a discolored ring on the floor around the toilet, and the cove/base molding was separating from the wall under the sink. The toilet room had a foul odor.
m. room [ROOM NUMBER], upon entering the toilet/bathroom at 2:55 PM a strong unpleasant odor was revealed and confirmed by the Maintenance Director. The cove molding behind the toilet appeared to be deteriorating due to decay and rust indentation into the wall.
n. room [ROOM NUMBER], observations of the toilet room door frame on the 311 side revealed bubbly rusted paint along a 2 foot stretch up from the floor. Rust on the floor around the door frame and a discolored ring on the floor around the toilet were observed. The wooden bathroom door on the room [ROOM NUMBER] side was noted with holes and indentations that were rough and splintered.
o. room [ROOM NUMBER], original observations on 11/18/19 revealed a fist sized hole in the wall above the A-bed. On 12/6/19 the area appeared to be an incomplete repair. New wallboard and unfinished rough spackling was present. The Maintenance Director acknowledged the original destruction and relayed a difficulty in completing repairs. There were observations of cove molding separating from the bathroom walls.
p. room [ROOM NUMBER], observed on the outside corner wall of the bathroom ([NAME] out in to the room) next to the A-bed was an exposed damage section of metal corner bead. At least 2 feet of the metal corner bead was separated from the two outside corner walls. The maintenance director indicated that he was not informed of the destruction. The windowsills were dirty with areas of dirty ill repaired cracked dried spackling compound. There were strips of wallpaper separating and loosely hanging from the wall. Also observed was a stain on the floor where there was a previous closet/wardrobe. The cove/base molding was separating from the wall by the heater/AC unit.
q. Resident #63's room was originally observed on 11/14/19 at 2:44 PM and both residents were in the room at the that time. Resident #63 had expressed displeasure in the cleanliness and upkeep of the room. Resident #63 pointed to items on the windowsills that included a bottle of hydrogel and a near empty bottle of sterile water. On the other windowsill s/he pointed to a water bottle and crumpled paper towel while indicating the items have been there for a month. Resident #63 repeated several times just terrible .my home never looked like this. Resident #63 requested for the surveyor to look behind the head of his/her bed, with noted accumulations of dust on the bed frame and on the base molding. The cover to the heating/AC unit was off revealing much dirt and grim on the internal parts of the unit. On the environmental tour of 12/6/19 observations revealed peeling of paint in multiple spots on the windowsill (different paint color underneath) with noted dirt and grime. There were missing/broken slats in the vertical blinds of the window. There was stains on the floor from where the facility had removed a closet/wardrobe. The wall around the newer closet/wardrobe was not painted to match the rest of the wall. Observations of the bathroom revealed missing tiles along the wall opposite of the toilet and sink.
r. During the environmental tour on 12/6/19, observations revealed along the left side of the third-floor shower/bathing room was a wide baseboard with peeling, discolored, and what appeared to be damaged scraped areas. There were areas of missing cove/base tiles near the tub. Tile and/or wall board missing from the drain end of the tub. The tub itself was noted with discolored staining. The metal soap holder on the wall was tilted and loose on the wall. A 2 inch diameter hole was noted in the wall. The sink was noted separating from the wall with a lengthy crack in the caulking between the sink and wall. The wall opposite the sink observed with noted seam separations with gouges, nicks, and cuts along the wall. Rust was noted at the bottom of the bathroom door frame. In the large shower area (with two shower heads) multiple cracks in the tile were observed.
s. room [ROOM NUMBER] observations revealed stains on the ceiling tiles above the TV. Torn wallpaper noted on above the left-hand side of the light. On the wall under the hand sanitizer and boxed glove rack there was a gouged/scraped area approximately a foot long and 1 inch thick. The wooden bathroom door noted with scrapes in the wood veneer above the door handle. The lower two-foot area of the door was noted with scrapes and black markings. The same was noted on the inside of the door with multiple scraped areas and black markings in and on the wood veneer. The toilet cover originally observed on 11/15/19 at 9:19 AM was not seated properly on the back of the toilet. Maintenance fixed/adjusted the cover to properly sit on the back of the toilet during the environment tour. The sink drain pipe shown to have a gap where the pipe enters the wall. The Maintenance Director indicated that they would have to the replace the escutcheon plate. The vent in the ceiling above the toilet was noted to have a dust build up.
t. During the environmental tour, impromptu discussions were held, and acknowledgment that damage to walls, doors, and door frames was related to wheelchairs, electric chairs, and other medical devices. The Maintenance Director was asked how staff are to communicate concerns to the maintenance department and the Maintenance Director revealed that there were links in the Point Click Care Program for staff to report concerns electronically to the maintenance department. He indicated that there were many surveyor identified areas that he was not informed about. He added that he has never been informed of cove/base molding separations from the wall.
The environmental tour with the maintenance director concluded at 3:22 PM on 12/6/19.
u. Dead dried bugs in the first dining room originally observed on 12/6/19 at 2:00 PM were noted in the two back window tracks. A follow-up was conducted with the Environmental Service Director #26 on 12/9/19 at 8:30 AM. He acknowledged when shown the dead dried bugs in both window tracks in the back of the dining room. The windowsills were also noted with dirt and grime. The back-right window was noted to be dirty/hazy. He indicated that the issue was on the inside of the actual windowpanes.
v. Resident #49's room was observed on 12/9/19 9:45 AM. Resident #49 was in the room at the time and upon introduction, the resident informed the surveyor of environmental concerns. Observations included broken and missing vertical blind slates. Numerous areas of unfinished wall repairs noted on front wall under window, behind and to the left of the Resident #49's bed. There were stains in 2 ceiling tiles with noted torn and missing areas in the top wallpaper border. Both the exterior and interior of the wooden bathroom door had scrapes in the veneer along the bottom of the door. The floor around the toilet was stained and dirty. There was a 6 x 6 crumbling hole in the wall near the floor across from the toilet and a strip of floor tile 3 feet by 4 feet was missing in the floor along the same wall. There were stained ceiling tiles in the bathroom. The metal door frames on both entrances to the bathroom were noted with damaged scraped areas with missing paint.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on facility documentation review and staff interview it was determined the facility failed to timely report investigations to the Survey Agency, which was the Office of Health Care Quality (OHCQ...
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Based on facility documentation review and staff interview it was determined the facility failed to timely report investigations to the Survey Agency, which was the Office of Health Care Quality (OHCQ) within 24 hours of an alleged incident and the final report within 5 working days. This was evident for 11 of 33 residents (#127, #20, #125, #42, #76, #101, #129, #144, #152, #154, #155) reviewed for abuse.
The findings include:
1) Review of intake MD00129202 for Resident #127 on 11/21/19 revealed the resident reported that he/she was not provided needed care. The surveyor was not provided with documentation as to when the incident was sent to OHCQ and when the final report was sent.
The Director of Nursing (DON) was interviewed on 11/22/19 and could not provide any further documentation of when the initial and 5 day reports were sent to OHCQ.
2) Review of intake MD00144676 for Resident #20 on 12/2/19 revealed the resident reported on 8/30/19 that men had been coming into his/her room and doing various things over the previous 3 to 4 weeks. Review of the facility investigation failed to produce documentation as to when the initial report and the 5 day reports were sent to OHCQ.
The Director of Nursing (DON) was interviewed on 12/2/19 and could not provide any further documentation of when the initial and 5 day reports were sent to OHCQ.
3) Review of intake MD00130297 revealed Resident #125 reported a gold ring and money was missing on 8/13/18. The facility was unable to provide the surveyor with any documentation related to the facility report. The facility could not provide documentation that the incident was reported within 24 hours and that the final report was sent to OHCQ within 5 working days.
On 11/22/19 at 9:16 AM the DON stated she could not find any documentation.
4) Review of intake MD00140696 on 12/2/19 revealed that Resident #42 reported on 5/22/19 that staff turned the resident in a way that could hurt the resident as he/she requested they stop while they were performing incontinence care. The incident was reported to OHCQ on 5/22/19, however there was no final report or confirmation of the final report given to the surveyor.
5) Review of intake MD00134864 for Resident #76 on 11/26/19 revealed the resident stated he/she was attacked by a Geriatric Nursing Assistant (GNA) on 12/22/18. Review of documents attached to the incident revealed the incident was reported on 12/24/18 when the resident reported it, however there was no documentation of when the final report was sent to OHCQ.
An interview was conducted with the DON on 12/4/19 at 11 AM and the DON stated, that is all I have. I don't have anything else to show when the final report was sent.
6) Review of intake MD00140953 on 11/25/19 for Resident #101 revealed the resident reported that he/she was missing a bag along with money on 5/26/19. The initial report was sent to OHCQ on 5/27/19, however a final report was not given to the surveyor. On 11/25/19 at 2:58 PM the DON stated she had sent a follow-up report but could not provide evidence to the surveyor.
7) Review of intake MD00140013 on 11/25/19 for Resident #129 revealed the resident reported on 5/3/19 that he/she was missing money from his/her nightstand drawer. Review of facility documentation revealed the incident was first reported to OHCQ on 5/6/19. On 11/25/19 at 2:04 PM, the DON stated the incident was reported on 5/6/19 because that was when the resident had reported it, however a witness statement/ interview document was signed by the social worker and an LPN dated 5/3/19. The incident was not reported within 24 hours.
8) Review of intake MD00141144 on 12/3/19 for Resident #144 documented that on 5/31/19 the resident alleged that an incident occurred between an agency GNA and the resident on 5/28/19. Review of facility documentation revealed the incident was reported on 5/31/19, the date that the resident reported the incident, but there was no documentation that the final report was sent to OHCQ.
The DON was interviewed on 12/3/19 at 2:30 PM and stated that if the fax sheet was not in the packet then she didn't know where it was.
9) Review of intake MD00141358 for Resident #42 on 12/6/19 revealed an agency nurse reported at 8:30 AM on 6/6/19 that she heard the GNA yelling at the resident and refusing to answer his/her call light. The nurse reported that she heard the GNA yelling and cursing at the resident. The incident allegedly happened during the night shift between 6/5/19 and 6/6/19. The nurse failed to promptly report the incident and waited until 8:30 AM to report it to administration.
An interview was conducted on 12/9/19 at 1:25 PM with the previous Nursing Home Administrator (NHA) Staff #2. He stated that it allegedly happened sometime during night shift, but the agency nurse failed to report it timely.
10) Review of intake MD00139322 on 12/10/19 for Resident #152 revealed on 4/15/19 the resident was noted with decreased consciousness and respirations and the resident was found on the floor with an empty clear capsule beside him/her with a decreased level of consciousness. Narcan was administered. Narcan is a medication that is given to help reverse the effects of the narcotic. The incident was reported to OHCQ on 4/16/19, however the final report was not provided to the surveyor after the DON and NHA were asked.
Review of intake MD00140030 on 12/10/19 for Resident #152 revealed on 4/29/19 the resident was noted with increased lethargy and was difficult to arouse. Narcan was administered. The incident was reported to OHCQ on 4/29/19, however the final report was not provided to the surveyor.
On 12/11/19 at 11:08 AM the NHA Staff #3 confirmed there was no further information to give to the surveyor.
11) Review of intake MD00140033 on 12/11/19 for Resident #154 revealed the resident was found unresponsive and Narcan was administered. The incident occurred on 5/1/19. The facility was unable to provide the surveyor with documentation of when the incident was first reported to OHCQ and there was no investigation and final confirmation of the investigation being sent to OHCQ within 5 days.
An interview was conducted with the NHA Staff #3 on 12/9/19 at 11 AM. The NHA revealed the investigation could not be found.
12) Review of intake MD00145126 on 12/11/19 for Resident #155 revealed the resident was found on 9/10/19 in the bathroom by another resident and was very lethargic. The resident was administered Narcan and admitted to using an illicit substance. The facility was unable to provide the surveyor with confirmation that the incident was reported to OHCQ timely and was unable to provide the surveyor with an investigation.
An interview was conducted with the NHA Staff #3 on 12/9/19 at 11 AM. The NHA Staff #3 stated that they could not find the investigation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
18c) A review was conducted of (FRI) MD00130455 on 12/6/19. The facility reported that Resident #12 alleged that $7.00 and some cigarettes were missing from his/her room upon return from a hospital st...
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18c) A review was conducted of (FRI) MD00130455 on 12/6/19. The facility reported that Resident #12 alleged that $7.00 and some cigarettes were missing from his/her room upon return from a hospital stay on 8/16/18.
The facility report indicated: Staff interviewed, and no one saw any staff, visitors, or residents in the resident's room. The facility concluded it was unable to substantiate that misappropriation occurred.
The surveyor requested all of the facility's investigation documentation and was provided with a copy of the self-report form that was sent to the state agency, email receipt confirmations from the state agency, an interview of Resident #12 by Staff #9 a Social Worker, on 8/16/18 and a copy of the staffing schedule for 8/9/18 - 8/16/18. There was no documentation of interviews or statements from staff or other residents. The facility provided no other documentation to reflect that a thorough investigation was conducted in an attempt to determine the disposition of Resident #12's alleged missing items.
On 12/6/19 at 12:25 PM the Administrator, Staff #3 was asked for documentation of the staff interviews as per the facility's report and any additional investigative documentation. She indicated that she was unable to find that there was any interviews or additional documentation.
Based on interview and review of facility reported incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate incidents of missing property, alleged verbal and physical abuse and the administration of Narcan and report the results of all abuse allegation investigations to the State Survey Agency within 5 working days. This was evident for 17 of 33 residents (Resident #127, #101, #124, #125, #131, #132, #134, #122, #141, #76, #20, #148, #151, #154, #155, #152, #12) reviewed for abuse.
The findings include:
1) Review of intake MD00129202 for Resident #127 on 11/21/19 revealed the resident reported that he/she was not provided needed care. The surveyor was not provided with an investigation into the incident.
The Director of Nursing (DON) was interviewed on 11/22/19 and could not provide any further documentation and stated she didn't know where it was. The only documentation was a summary on the report sheet.
2) Review of intake MD00140953 on 11/22/19 for Resident #101 revealed the resident alleged he/she was missing a bag in the hallway which contained money and cigarettes on 5/26/19. The facility reported the incident on 5/27/19. Review of the facility's investigative documentation revealed a grievance form that was filled out by the social worker. There was also 1 employee written statement.
An interview was conducted with the Director of Nursing (DON) on 11/25/19 at 2:00 PM. The DON was asked if there were any further investigative notes and the DON stated that she had interviewed other staff but did not document the interviews or get signed statements.
3) Review of intake MD00129656 revealed Resident #124 reported a gold necklace and chain missing as well as a candy bar and a soda. The incident was reported to The Office of Health Care Quality (OHCQ); however, a thorough investigation was not done. The only information that was provided to the surveyor was a copy of the police report, the resident's inventory sheet and a statement from the DON.
On 11/22/19 at 9:16 AM the DON stated she had no further information to give the surveyor.
4) Review of intake MD00130297 revealed Resident #125 reported a gold ring and money was missing on 8/13/18. The facility was unable to provide the surveyor with any documentation related to the facility report. There was no evidence that an investigation was done.
On 11/22/19 at 9:16 AM the DON stated she could not find any documentation.
5) Review of intake MD00132082 on 11/22/19 revealed documentation that Resident #131 stated that he/she reported he/she dropped his/her wallet and when it was returned there were (4) $5.00 bills missing and a bank card. The resident insisted that the wallet was dropped on the smoking patio between 2:30 PM and 3:30 PM on 9/30/18.
Review of facility documentation included a statement from the DON and a statement from the resident. There was no investigation documented and no resident or staff interviews.
An interview was conducted on 12/2/19 at 9:34 AM with the DON and she stated that she asked other residents that were out there, but no one would talk to her. This was not documented in the investigation.
6) Review of intake MD00144963 on 11/22/19 for Resident #132 on 11/25/19 revealed documentation that the resident reported money missing from his/her nightstand drawer and the resident suspected the roommate took the money, however he/she did not see it happen.
Review of the facility investigation indicated that the facility only interviewed the resident and 1 Geriatric Nursing Assistant. There was no interview of the roommate or any other residents or employees. The investigation was not thorough.
An interview was conducted on 12/3/19 at 9:30 AM with the DON. The DON was asked if anyone else was interviewed. She said she would look to see. The DON came back and said she had no further information.
7) Review of intake MD00144421 revealed Resident #134 reported on 8/22/19 that money was on the bedside table when the resident went to bed and when the resident woke up the money was missing. The facility reported the incident to OHCQ but failed to do a thorough investigation. The investigation that was provided to the surveyor did not include staff interviews or investigation as to where the money could have gone.
On 12/3/19 at 10:31 AM the Nursing Home Administrator (NHA) Staff #3 was interviewed and confirmed that she had seen the trend of investigations failing to be thorough.
8) Review of intake MD00143113 on 11/25/19 for Resident #122 revealed the resident reported that money was missing. Review of the facility investigative report only had the intake interview from the resident and the care plan. No investigation was provided to the surveyor.
An interview was conducted on 12/3/19 at 10:20 AM with the NHA Staff #3 who confirmed that she was finding the same issue with facility reports.
9) Review of facility reported incident MD00130510 on 11/26/19 revealed that Resident #141 reported on 8/20/18 that on 8/18/18 GNA #61 told the resident, [expletive] you and gave the resident the middle finger. The resident sustained a fall on the patio and the resident reported that GNA #61 stated, if they would stop self-medicating they would not fall. There was a verbal altercation between GNA #61 and Resident #141.
Verbal abuse was substantiated by the facility and GNA #61 was reported to the Board of Nursing, however a thorough investigation was not done and there were no resident interviews done. The resident fell outside on the patio in front of several residents who witnessed the altercation.
An interview was conducted on 12/10/19 at 9:40 AM with the NHA Staff #3. The NHA Staff #3 acknowledged that she is seeing a trend where a thorough investigation was not being done and that she planned to do an in-service on thorough investigations.
10) Review of intake MD00134864 for Resident #76 on 11/26/19 revealed the resident stated he/she was attacked by a Geriatric Nursing Assistant (GNA) on 12/22/18. Review of documents attached to the incident revealed the charge nurse was not interviewed even though the GNA stated she reported the concern to the charge nurse. Other residents and staff were not interviewed.
An interview was conducted with the DON on 12/4/19 at 11 AM and the DON stated, that is all I have. The DON was made aware that the investigation was incomplete.
11) Review of intake MD00144676 for Resident #20 on 12/2/19 revealed the resident reported on 8/30/19 that men had been coming into his/her room and doing various things over the previous 3 to 4 weeks. Review of the facility investigation revealed that no residents or staff were interviewed during the investigation. The facility failed to do a thorough investigation.
The Director of Nursing (DON) was interviewed on 12/2/19 and could not provide any further documentation.
12) Review of intake MD00144260 on 12/3/19 for Resident #101 revealed that the resident reported missing money and cigarettes on 8/16/19. The facility investigation was reviewed, and it was documented that the room was searched to ensure that the missing items were not misplaced. However, there was no documentation that interviews of staff and other residents to validate findings were done. The investigation was not thorough.
An interview was conducted with the NHA Staff #3 on 12/10/19 at 9:40 AM. She stated she has looked at the facility reports and confirms that thorough investigations were not being done.
13) Review of intake MD00140687 on 12/9/19 revealed Resident #148 alleged verbal abuse by a therapist. The resident reported alleged abuse on 5/22/19 to have taken place on 5/15/19 or 5/16/19. The resident reported to his/her cousin on 5/22/19, who reported it to the facility.
Review of the facility investigation revealed the facility was not able to substantiate the abuse, however the facility failed to do a thorough investigation. The facility failed to interview other staff members or residents during the investigation.
14) Review of intake MD00144261 on 12/9/19 revealed Resident #151 approached the nurse and complained of being short of breath and very anxious. During the assessment the resident admitted to using street drugs. Review of documentation given to the surveyor from the DON failed to produce a thorough investigation into the incident. There were no interviews with staff or any other residents.
An interview was conducted with the DON on 12/11/19 at 9:34 AM. The DON was asked if there was anything else to the investigation. She said she would have to go look at her soft file. The DON did not bring any further documentation to the surveyor.
An interview was conducted on 12/11/19 at 10:05 AM with the NHA Staff #3. She confirmed there was no further investigation to give to the surveyor.
15) A review of incident MD00140033 for Resident #154 was conducted on 12/9/19 and revealed the resident was found unresponsive and Narcan was administered. Narcan is a drug that can treat a narcotic overdose in an emergency. The incident occurred on 5/1/19. The facility was unable to provide the surveyor with documentation that an investigation had been done.
An interview was conducted with the NHA Staff #3 on 12/9/19 at 11 AM. The NHA Staff #3 revealed the investigation could not be found.
16) Review of incident MD00145126 on 12/9/19 for Resident #155 revealed the resident was found on 9/10/19 in the bathroom by another resident and was very lethargic. The resident was administered Narcan and admitted to using an illicit substance. The facility was unable to provide the surveyor with documentation that an investigation was done.
An interview was conducted with the NHA Staff #3 on 12/9/19 at 11 AM. The NHA Staff #3 stated that they could not find the investigation.
17) Review of incident MD00139322 on 12/10/19 for Resident #152 revealed on 4/15/19 the resident was noted with decreased consciousness and respirations and the resident was found on the floor with an empty clear capsule beside him/her with a decreased level of consciousness. Narcan was administered. The incident was reported to OHCQ on 4/16/19, however there was no investigation. The only documentation with the incident report was a behavioral contract and a change in condition form. There were comments on the event form with no dates or times of any interviews. The resident was no longer in the facility.
Review of incident MD00140030 on 12/10/19 for Resident #152 revealed on 4/29/19 the resident was noted with increased lethargy and was difficult to arouse. Narcan was administered. There was no investigation.
On 12/11/19 at 11:08 AM the NHA, Staff #3 confirmed there was no further information to give to the surveyor.
18a) Review of Resident #12's medical record revealed the resident was cognitively intact with adequate hearing and speech for communication.
On 12/3/19 review of the medical record revealed the resident reported abuse by a staff member on 11/1/19. The Director of Nursing (DON) reported that she had completed a self report (FRI) for this incident. Consultation with the state survey office revealed the initial report had been received but the final 5 day report had not.
On 12/04/19 at 3:33 PM surveyor reviewed with DON the concern that the 5 day follow up report had not been received by the state survey office. As of time of survey exit on 12/11/19 no additional documentation was provided that indicated the final report had been submitted to the survey office when due in November 2019.
18b) On 12/3/19 review of MD00147124 revealed that on 10/14/19 Resident #12 made an abuse allegation. The initial FRI report was submitted to the survey agency on 10/14/19. The final 5 day report was received by the state survey office on 11/1/19, which is more than one week after it was due.
On 12/5/19 surveyor reviewed the concern regarding facility failure to submit 5 day investigation results with Administrator, Staff #3 and the DON.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
2) Review of Resident #14's medical record on 11/15/19 at 11:31 AM revealed on 9/4/19 at 11:02 PM, in a Nursing Home to Hospital Transfer Form, the nurse documented that Resident #14 was transferred t...
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2) Review of Resident #14's medical record on 11/15/19 at 11:31 AM revealed on 9/4/19 at 11:02 PM, in a Nursing Home to Hospital Transfer Form, the nurse documented that Resident #14 was transferred to the hospital. Review of the letter notifying the resident's representative of the hospital transfer failed to reveal information regarding the resident's appeal rights or Ombudsman contact information.
3) On 11/19/19 at 10:09 AM, review of Resident #13's medical record revealed the resident was transferred to the hospital on 8/9/19. Review of the letter notifying the resident's representative of the hospital transfer revealed notification of the reason for the transfer, however, the letter failed to include information regarding the resident's appeal rights or Ombudsman contact information.
4) Review of Resident #49's medical record on 11/21/19 at 9:11 AM revealed documentation that Resident #49 was transferred to an acute care facility on 9/14/19. Review of the letter notifying the resident's representative of the hospital transfer revealed notification of the reason for the transfer, however, the letter failed to include information regarding the resident's appeal rights or Ombudsman contact information.
On 11/19/19 at 2:06 PM, Administrator,Staff #2 and Administrator, Staff #3 confirmed the findings.
Based on medical record review and interview it was determined that the facility failed to include the required statement of the resident's appeal rights and Ombudsman contact information in the written notice of transfer. This was found to be evident for 4 of 8 residents (Resident #27, #14, #13, #49) reviewed for hospitalization and has the potential to affect any resident transferred to the hospital.
The findings include:
1) On 11/15/19 review of Resident #27's medical record revealed the resident had been discharged to the hospital in August 2019. Review of the letter provided to the resident regarding the transfer failed to include information regarding the resident's appeal rights or contact information for the Ombudsman.
On 11/19/19 at 2:05 PM Administrator #2 confirmed no additional information was being provided at time of hospital discharge regarding appeal rights or Ombudsman contact information. Surveyor then reviewed the concern that the letter being used failed to include the required information regarding appeal rights and Ombudsman information with Administrator #2 and #3.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected multiple residents
2) Review of Resident #13's medical record on 11/19/19 at 10:09 AM revealed that on 8/9/19 at 11:57 PM, in a transfer note, the nurse documented that Resident #13 had an unplanned transfer. Continued ...
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2) Review of Resident #13's medical record on 11/19/19 at 10:09 AM revealed that on 8/9/19 at 11:57 PM, in a transfer note, the nurse documented that Resident #13 had an unplanned transfer. Continued review of Resident #13's medical record revealed documentation to indicate the resident was sent to an acute care facility secondary to a gastrostomy tube (GT) blockage and subsequent replacement of his/her GT. There was no documentation in Resident #13's medical record to indicate that the resident received an explanation as to why he/she was being transferred to the hospital and the potential response of the resident's understanding. The Director of Nurses (DON) was made aware of these findings on 11/19/19 at 1:40 PM.
3) Review of Resident #14's medical record on 11/15/19 at 11:31 AM revealed on 9/4/19 at 11:02 PM, in a Nursing Home to Hospital Transfer Form, the nurse documented that Resident #14 was transferred to the hospital due to having uncontrolled pain. Continued review of the medical record failed to reveal documentation that the resident received an explanation as to why he/she was being transferred to the hospital and the potential response of the resident's understanding.
4) Review of Resident #49's medical record on 11/21/19 at 9:11 AM revealed documentation that Resident #49 was transferred to an acute care facility on 9/14/19. On 9/14/19 at 10:00 PM, in a transfer note, the nurse wrote that the resident had an unplanned transfer and the contact person was notified of transfer. Continued review of the medical record revealed documentation that the resident was hospitalized for pyelonephritis (kidney infection) and sepsis (infection in blood stream). There was no documentation in the medical record that the resident received an explanation as to why he/she was being transferred to the hospital and the potential response of the resident's understanding.
Continued review of Resident #49's medical record revealed the resident had returned to the facility on 9/20/19 and was transferred back to an acute care facility on 10/1/19. On 10/1/19 at 10:59 PM, in a Nursing Home to Hospital Transfer Form, the nurse documented that Resident #49 was transferred to the hospital due to abnormal vital signs.
Based on medical record review and staff interview it was determined the facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident for 4 of 8 residents (Resident #36, #13, #14, #49) reviewed for hospitalization.
The findings include:
1) Review of the medical record for Resident #36 on 12/5/19 documented that on 11/19/19 at 3:16 PM Resident #36 was sent to the emergency room for a change in mental status and abnormal laboratory results.
There was no written documentation found in the medical record that Resident #36 was oriented and prepared for the transfer in a manner that the resident could understand and there was no documentation of the resident's understanding of the transfer in the medical record. An interview with the Director of Nursing on 12/5/19 at 4:30 PM confirmed the findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1g) Review of Resident #32's medical record on 11/25/19 at 11:05 AM revealed documentation that Resident #32 had diagnoses that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1g) Review of Resident #32's medical record on 11/25/19 at 11:05 AM revealed documentation that Resident #32 had diagnoses that included diabetes, insomnia and Bipolar Disorder (manic depression). Review of Resident #32's physician orders revealed a 4/28/19 order for Actos (Pioglitazone), (diabetes medication), by mouth every day for diabetes, a 5/4/19 order for Metformin (Glucophage) (diabetes medication) by mouth 2 times a day for diabetes, a 5/12/10 order for Tradjenta (Linagliptin) (diabetes medication) by mouth every day for diabetes and an 8/19/19 order for Insulin Lispro (Humalog) subcutaneous injection every day for diabetes. Continued review Resident #32's physician orders revealed a 7/20/19 order for Melatonin (hormone used as a sleep aid) by mouth every day at bedtime for insomnia, an 8/10/19 order for Trazodone (antidepressant) every day at bedtime for insomnia and a 10/23/18 order for Depakote ER (extended release) (Divalproex Sodium ER) (anti-seizure medication used to treat mood disorders) by mouth every day for Bipolar. Review of Resident #32's September 2019 MAR (medication administration record) revealed documentation that Resident #32 received the above medications as ordered.
Review of Resident #32's quarterly MDS assessment with an ARD of 9/17/19 revealed MDS inaccuracies. Section I, Active diagnosis failed to capture Resident #32's active diagnosis of Diabetes, Insomnia and Manic depression. On 11/27/19 at 9:50 AM, the MDS Coordinator #2, confirmed the MDS inaccuracies.
1h) Review of Resident #10's medical record on 12/2/19 at 10:55 AM revealed the resident had diagnosis that included unspecified paraplegia (impairment in motor or sensory function of the lower extremities) and was non-ambulatory (unable to walk). Review of Resident #10's quarterly MDS assessment with an ARD of 8/17/19 revealed Section G, Functional Status, C. Walk in Room was coded 7, activity occurred only once or twice and required one-person physical assist and D. Walk in Corridor was coded 7, activity occurred only once or twice and required on-person physical assist which was inaccurate as Resident #10 was non-ambulatory.
Review of Resident #10's August 2019 MAR (medication administration record) revealed the resident received Midodrine (medication to treat hypotension, low blood pressure) by mouth 2 times a day for hypotension and Mirtazapine (Remeron) (antidepressant) by mouth on time a day for depression. Review of Resident #10's quarterly MDS assessment with an ARD of 8/17/19, Section I, Active Diagnosis revealed the MDS failed to capture that Resident #10 had the diagnosis of hypotension and depression.
On 12/2/19 at 3:33 PM, during an interview, MDS Coordinator #1 indicated documentation was overlooked and MDS Coordinator #2 stated that it was an oversight and confirmed the MDS inaccuracies. On 12/3/19 at 9:40 AM the Director of Nurses was made aware of the findings.
1i) On 12/5/19 at 9:00 AM, a review of Resident #14's medical record revealed a urine c/s (culture & sensitivity) (test for bacteria and susceptible antibiotic) that reported on 8/1/10 that the resident had a UTI (urinary tract infection). Continue review of Resident #14's medical record revealed the resident was hospitalized in mid-August 2019, treated for a UTI and returned to the facility. On 8/16/19, in a hospital discharge summary, the physician documented Resident #14's diagnosis included suprapubic catheter (tube used to drain urine that is inserted in the bladder through an incision in the belly) associated UTI . The physician documented the resident had a history of recurrent UTI's, and the resident's urine culture was positive for a UTI which was treated with IV antibiotics. Review of Resident #14's August 2019 MAR (medication administration record) revealed documentation that the resident received Ampicillin (antibiotic) by mouth on 8/1/19 and 8/2/19 for UTI, and the antibiotic Ertapenem (Ivanz) intravenously (IV), on 8/17/19 thru 8/20/19 for treatment of UTI.
Review of Resident #14's quarterly MDS assessment with an ARD of 8/18/19 revealed Section I, Active Diagnosis, 12300, Urinary Tract Infection (UTI) (Last 30 days) was blank. There was no documentation in the MDS to indicate the resident had a UTI in the past 30 days. Review of Resident #14's quarterly MDS assessment with an ARD of 8/28/19, Section I, Active Diagnosis, 12300, Urinary Tract Infection (UTI) (Last 30 days) was blank. There was no documentation in the MDS to indicate the resident had a UTI in the past 30 days.
The Director of Nurses was made aware of the above findings on 12/6/19 at 2:29 PM.
3) Review of Resident # 23's medical record revealed that the Resident was admitted to the facility in July 2019 with diagnosis to include depression and atrial fibrillation. Depression is a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. Atrial fibrillation is an irregular, often rapid heart rate that commonly causes poor blood flow.
Review of Resident #23's physician orders revealed the resident was ordered Eliquis 5 mg two times a day on 7/13/19 for atrial fibrillation. Eliquis is an anticoagulant used to treat and prevent blood clots and to prevent stroke in people with atrial fibrillation. Further review of Resident #23's physician orders revealed the resident was ordered Sertraline 25 mg once daily on 8/21/19 for depression. Sertraline affects chemicals in the brain that may be unbalanced in people with depression, panic, anxiety, or obsessive-compulsive symptoms.
Review of Resident # 23's 11/19/19 quarterly MDS assessment Section Medications received N0410 C. Medication received: Days: Antidepressant zero and N0410 E. Medication received: Days: Anticoagulant zero.
Review of Resident #23's November 2019 Medication Administration Records for November 1st through November 19th, 2019 revealed the Resident received Eliquis every day 11/1/19 through 11/19/19 and Sertraline every day 11/1/19 trough 11/19/19.
Interview with MDS Nurse #1 on 12/5/19 at 1:45 PM confirmed the MDS quarterly assessment Section N0140 on 11/19/19 was coded incorrectly for antidepressant and anticoagulant medications received.
Interview with the Director of Nursing on 12/6/19 at 7:56 AM confirmed that the facility staff failed to accurately document medications received for a resident on the MDS.
4) Review of Resident #4's medical record on 12/4/19 at 10:10 AM revealed a quarterly MDS with an Assessment Reference Date (ARD) 11/6/19. Section C Cognition indicated not assessed and Section D Mood was not completed. Both sections were signed by Staff #9 a Social Worker on 12/2/19 as completed. The quarterly assessment was to have been completed by 11/20/19, 14 days after the ARD.
Social Worker #9 was interviewed on 12/4/19 at 11:14 AM. She confirmed these findings and that she is responsible for completing Sections C and D of the MDS assessment. When asked why the sections were not completed, she indicated that the Clinical Reimbursement Coordinator (CRC) failed to notify her when these assessments were due.
During an interview on 12/4/19 at 2:50 PM, Staff #11 and #12 the CRC's were asked how other departments know when the MDS assessments are due. They indicated that they do not notify other responsible departments but will go over the ones (MDS assessments) that are time sensitive during the morning meeting if they need to be finished. They were made aware and confirmed that Sections C and D of Resident #4's Quarterly MDS with the ARD 11/6/19 were not completed. They indicated they were not aware that it had not been done.
The Director of Nursing was made aware of these concerns on 12/6/19 at 11:07 AM.
Cross reference F 642.
Based on medical record review and staff interview, it was determined the facility staff failed to 1) ensure Minimum Data Set (MDS) assessments were accurately coded (Resident #119, #123, #135, #36, #145, #120, #32, #10, #14), 2a) accurately assess the use of an anticoagulant medication (#369), 2b) accurately assess the use of CPAP machine (#117), 3) accurately document medications (#23), 4) accurately reflect the resident's cognitive and mood status (#4). This was evident for 13 of 104 residents reviewed for further investigation.
The findings include:
The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
1a) Review of the admission MDS for Resident #119 with an assessment reference date (ARD) of 3/12/19, Section I6500 Vision, failed to capture the diagnosis of glaucoma. Review of Resident #119's March 2019 Medication Administration Record (MAR) documented the administration of eye drops Dorzolamide HCl-Timolol Mal Solution 22.3-6.8 mg/ml twice per day for glaucoma and Prednisolone acetate suspension 1% every day in the left eye every 2 hours for glaucoma, that was started on 3/7/19.
Further review of the March 2019 MAR revealed the resident took the medication Flomax 0.4mg every day for BPH, Benign Prostatic Hyperplasia. BPH was not captured on the MDS in Section I, diagnosis.
Continued review of Resident #119's medical record revealed Section J0100 pain management, received scheduled pain medication regimen, was coded no. Review of the March 2019 MAR documented the resident received Oxycodone ER 10 mg every 12 hours for chronic pain.
Additionally, Section J1700 Fall history on admission was not assessed even though the resident was documented as having a fall prior to admission that resulted in a puncture wound near the anal region from the electric wheelchair.
On 12/2/19 at 11:51 AM an interview was conducted with MDS Coordinator #1, who confirmed the errors.
1b) Review of the medical record for Resident #123 revealed an admission MDS with an ARD of 3/14/19. The staff failed to assess falls prior to entering the facility in Section J1700 and failed to capture a fall that occurred in the afternoon on 3/8/19 in Section J1800. Section J0100B, received PRN (when needed) pain medications or was offered and declined, documented 0 which indicated the resident did not receive any PRN pain medications.
Review of Resident #123's March 2019 MAR revealed documentation that the resident received the PRN pain medication Tramadol 50 mg on 3/10/19 at 2100 (9 PM) and on 3/14/19 at 8:57 AM.
On 12/2/19 at 2:02 PM the MDS errors were discussed with the Director of Nursing (DON).
1c) Review of the medical record for Resident #135 on 12/4/19 revealed a Certified Registered Nurse Practitioner's (CRNP) progress note dated 2/1/19 which documented that the resident had Type 2 diabetes mellitus and was to receive Lantus 25 units every evening. Additionally, the resident had obstructive sleep apnea.
Review of Resident #135's five day MDS assessment with an ARD of 2/6/19 failed to capture diabetes mellitus in Section I2900 and obstructive sleep apnea in Section I8000, other diagnoses.
1d) Review of Resident #36's admission MDS assessment with an ARD of 9/24/19 failed to capture the diagnosis of diabetes in Section I2900 and hyperlipidemia in section I3300. Review of Resident #36's September 2019 MAR documented that the resident received insulin 65 units every evening and the medication Atorvastatin for hyperlipidemia.
Review of Resident #36's discharge return anticipated MDS assessment with an ARD of 11/19/19, Section I2900 Diabetes Mellitus, was not checked. MDS Coordinator #1 confirmed the errors on 12/5/19 at 1:52 PM.
1e) Review of Resident #145's discharge return not anticipated MDS assessment with an ARD of 10/29/18, Section I diagnoses, failed to capture bipolar disorder and benign prostatic hyperplasia. Review of Resident #145's October 2018 MAR documented that the resident took Cariprazine at bedtime and Oxcarbazepine twice per day for bipolar disorder and Flomax every day for benign prostatic hyperplasia.
Continued review of the 10/29/18 MDS, Section J1800, any falls since admission or prior assessment documented 0. Review of progress notes revealed a 10/23/18 at 23:52 (11:52 PM) change in condition note that the resident had a fall.
On 12/9/19 at 10:35 AM MDS Coordinator #2 confirmed the errors.
2a) On 12/4/19 review of Resident #369's medical record revealed the resident had orders, in effect since 11/2/19, for Heparin injections every 12 hours for clotting prevention. Heparin is an anticoagulant medication that assists in the prevention of blood clots.
Review of the Medication Administration Record for November 2019 revealed the resident received the anticoagulant medication November 2nd thru [DATE].
Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 11/7/19, revealed documentation that indicated the resident had not received any anticoagulant medication during the seven day look back period.
On 12/4/19 at 2:15 PM the MDS Nurse #12 confirmed that the resident had received an anticoagulant during the assessment period and this information was not included in the MDS assessment.
2b) On 12/5/19 review of Resident #117 medical record revealed the resident had orders, in effect since 9/13/19, for CPAP for obstructive sleep apnea to be applied at time of sleep and removed in the morning.
Review of the Minimum Data Set assessment, with an assessment reference date of 11/1/19, Section O Respiratory Treatments failed to include the resident's use of the CPAP machine.
Cross reference to F 695.
1f) A review of the medical record for Resident #120 was conducted on 12/4/19 documents that Resident #120 was discharge to the community/home on 9/13/19. A nursing progress note was written on 9/13/19 by the Director of Nursing indicating that the resident left against medical advice out the front door. Review of the MDS assessment with an assessment reference date (ARD) of 9/13/19 indicated that the resident was discharged to the hospital. The MDS assessment for Discharge Status at A2100 was inaccurately coded on 9/17/19 by the MDS coordinator #12.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3h) On 11/19/19 at 9:35 AM an interview with Resident #42 was conducted. Resident #42 stated he/she was to have a urinary straig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3h) On 11/19/19 at 9:35 AM an interview with Resident #42 was conducted. Resident #42 stated he/she was to have a urinary straight catheter placed every 6 hours, at midnight, 6:00 AM, noon, and 6:00 PM.
A review of Resident #42's medical record was conducted on 11/19/19 at 11:16 AM. Review of the physician orders revealed for Resident #42 to have intermittent catheterization by nursing every 6 hours for a neurogenic bladder. Further record review revealed a care plan effective on 10/9/19 which stated that Resident #42 experiences urinary retention related to quadriplegia and needs a straight catheter placed every 4 hours.
On 11/21/19 at 03:05 PM during an interview with the 3rd Floor Unit Manager (Staff #5) she stated she was unaware that there was a discrepancy with the physician's orders and the care plan and confirmed surveyor's findings.
The Director of Nursing was made aware of the surveyor's findings on 11/21/19.
Cross Reference F 684
5a) Hemodialysis or dialysis is a treatment for individuals with kidney failure. Kidneys clean the blood and perform other necessary duties. When the kidneys are unable to perform these duties then the body needs the process of dialysis to perform the functions.
An interview with Dialysis contracted staff #46 on 11/19/19 at 11:30 AM, revealed that Resident #114 had an issue with his/her blood pressure dropping during dialysis and did not always get the medication that was ordered for it before the dialysis treatment started.
Review of the medical record on 11/19/19 at 1:04 PM, revealed on the physician's order summary dated 11/2019 an order for Midodrine 10 mg Give 1 tablet by mouth every 8 hours as needed for hypotension, B/P (blood pressure) < (less than) 90 systolic and written in the special instructions was give on dialysis days. Midodrine was a medication used to increase a person's blood pressure and requires careful monitoring.
However, review of the dialysis care plan initiated on 10/23/19, revealed a goal that the hemodialysis access will remain patent (open) for 90 days and the interventions that were listed were generalized versus resident-centered. The care plan did not include that the resident was ordered a medication for low blood pressure to be administered before he/she started dialysis treatment, it did not indicate this resident had a known risk for their blood pressure dropping during and after dialysis treatments, nor did it indicate the location and type of dialysis access, as it referred to 2 different types of dialysis access and indicated to monitor both.
An interview with the Director of Nursing on 11/19/19 at 1:28 PM, she agreed the information should have been on the care plan.
4a) On 11/18/19 at 12:20 PM and on 11/22/19 at 3:00 PM, Resident #32 was observed to be wearing a nasal cannula (NC) oxygen (O2) tubing connected to an oxygen concentrator set at 2.5 LPM (liters per minute). On 11/22/19 19 at 3:00 PM, a review of Resident #32's physician orders revealed a 10/22/18 order for O2 at 2 LPM via NC continuous for COPD (chronic obstructive pulmonary disease). On 11/22/19 at 3:25 PM, along with Staff #8, observation was made of Resident #32 wearing a NC connected to a O2 concentrator set a 2.5 LPM. At that time, Staff #8 confirmed the observation and confirmed that Resident #32's oxygen flow rate was to be set at 2 LPM, per the physician's order.
Review of Resident #32's care plans revealed a care plan: 1) resident exhibits or is at risk for respiratory complication AEB (as exhibited by) COPD & CHF (congestive heart failure), 2) resident is unable to lie flat while in bed that had an intervention O2 as ordered via NC @ 2 LPM. The facility failed to follow the resident's care plan by failing to ensure the residents oxygen rate was set at 2 LPM.
On 11/25/19 at 11:26 AM, continued review of Resident #32's medical record revealed a 6/22/19 physician's order to weigh Resident #32 every Monday on day shift, starting 6/24/19, indicating the resident should be weighed every week. Review of Resident #32's weight summary since 6/24/19 revealed the resident had a weight recorded on 7/2/19, 8/1/19, 8/26/19, 9/12/19, 10/25/19 and 11/19/19 which was 7 times in 22 weeks. The facility staff failed to follow the physician's order by failing to obtain Resident #32's weight every week.
Review of Resident #32's care plans revealed a care plan: 1)Resident exhibits or is at risk for cardiovascular symptoms or complication r/t HTN (hypertension)/COPD/CHF which included the intervention monitor weight as ordered and a care plan Resident is at nutrition risk r/t obesity, CHF, DM2 (diabetes), weight fluctuations associated with diuretic use that had an intervention that include Weigh per protocol and weekly weights ordered by MD. The facility staff failed to follow Resident #32's care plan by failing to monitor the resident's weight weekly as ordered.
The Director of Nurses was made aware of these findings on 11/26/19 at 3:20 PM
Cross Reference F 684
4b) Resident #13's medical record was reviewed on 11/19/19 at 10:09 AM. Resident #13's most recent quarterly assessment with a reference date of 8/25/19 documented that indicated Resident #13 required extensive assistance with his/her ADLs (activities of daily living). Review of Resident #13's care plans revealed a care plan resident/patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility. There was no care plan goal. The care plan had 2 interventions, 1) provide resident/patient with extensive assist of 1 for bed mobility and 2) provide resident/patient with extensive total assist of 2 for transfers using a Hoyer lift. The care plan was not resident centered and failed to include person-specific goals with measurable objectives and interventions.
Also, the resident had a care plan, Resident #13 requires various levels of assistance with ADLs, he/she needs assistance of 1 staff member to complete personal grooming, bathing after 2 member Hoyer transfer, and dressing. He/she is dependent for tube feeding; however after set up is independent for feeding and after 2 staff members mechanical transfers him in/out of motorized w/c (wheel chair) he/she is independent for locomotion w/n (within) facility, that had the goal Resident's ADL care needs will be anticipated and met in order to maintain the highest practicable level of functioning and physical well-being x 90 days. The care plan goal to anticipate the resident's care needs was a staff goal, not a resident centered goal with measurable objectives. Continued review of the resident's care plans failed to reveal a comprehensive care plan with measurable goals and objectives to assist the resident to attain or maintain his/her highest practicable well-being and prevent avoidable decline with his/her ADLs.
4c) On 11/20/19 at 11:07 AM, Resident #19's medical record was reviewed. A review of Resident #19's most recent MDS assessment with a reference date of 9/11/19 revealed documentation that indicated Resident #19 was severely cognitively impaired and dependent on staff for extensive assistance with ADLs, including personal hygiene. Review of Resident #19's care plans failed to reveal a comprehensive care plan had been developed to meet Resident #19's ADL needs.
4d) On 12/3/19 at 12:39 PM, review of Resident #10's medical record revealed documentation that Resident #10's diagnosis included a history of traumatic brain injury, paraplegia (impairment in motor or sensory function of the lower extremities) and contractures of muscle, multiple sites. Review of Resident #10's most recent MDS assessment with a reference date of 8/17/19, Section G. Functional Status documented that Resident #10 was dependent on staff for all activities of daily living, including positioning and documented that Resident #10 had functional limitation in range of motion (ROM) on one side of his/her upper extremity, and impairment on both lower extremities.
Review of Resident #10's care plans failed to reveal a plan of care had been developed to address the resident's left-hand contracture and his/her limited range of motion. Continued review of the medical record failed to reveal evidence that Resident #10 was receiving services to prevent further decline in the resident's range of motion.
Cross reference F 688
4e) On 12/5/19 at 9:00 AM, a review of the resident's medical record revealed Resident #14 had diagnosis that included muscle weakness and documentation indicating the resident was unable to walk independently. Review of Resident #14's physician progress notes revealed, on 10/17/19, 11/18/19, 11/26/19 and 12/1/19, the physician documented the resident was post-surgery with inability to walk, right sided weakness and leg weakness. On 11/27/19, in a hospital discharge note, the physician documented Resident #14's discharge diagnosis included paraplegia (impairment in motor or sensory function of the lower extremities) with cervical spine injury.
Review of Resident #14's care plans failed to reveal a comprehensive, resident centered care plan had been developed to address Resident #14's limited mobility.
The Director of Nurses was made aware of these findings on 12/6/19 at 2:07 PM.
Cross Reference F 676
3a) Resident #58's medical record was reviewed on 11/21/19. The resident's diagnoses included but were not limited to Hemiplegia and hemiparesis (weakness or inability to move on one side of the body) following other cerebrovascular disease affecting right dominant side, diabetes with diabetic polyneuropathy [damage or disease affecting peripheral nerves (fingers/toes) featuring weakness, numbness and burning pain], general muscle weakness and difficulty in walking.
A plan of care was developed for: Risk for decreased ability to perform ADL(s) (Activities of Daily Living) in bathing, grooming, personal hygiene, dressing, eating bed mobility, transfer, locomotion, toileting related to Impaired balance/dizziness, limited range of motion and limited mobility.
The residents goals:
A) Will maintain highest capable level of ADL ability throughout the next review period as evidenced by his/her ability to perform [specify ADL's] and least level of support needed to perform. The goal did not include measurable objectives.
B) Will improve current level of function in grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting by next review date. The goal did not identify how staff would measure the resident's improvement or lack of improvement for the ADL's identified as it did not indicate what his/her current level of function was.
The interventions were:
i) Monitor conditions that may contribute to ADL decline.
ii) Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted.
iii) Monitor for complications of immobility (e.g., pressure ulcers, muscular atrophy, contractures, incontinence, urinary/respiratory infections).
iv) Bed rails used as an enabler.
The facility failed to identify Resident #58's individual functional limitations, the level of assistance required to maintain ADL's and interventions that would assist the resident in achieving or maintaining his/her highest practicable level of ADL functioning.
The Director of Nursing was made aware of the above concerns on 12/06/19 at 11:07 AM.
3b) Facility Reported Incident (FRI) MD00136192 involving Resident #149 was reviewed on 12/11/19. The reported indicated that in January 2019 Resident #149 was very somnolent and only responded to loud verbal stimuli then would fall back asleep. The facility staff suspected a drug overdose. The facility staff administered a dose of Narcan (a medication used to counteract the effects of narcotics when an overdose is suspected). The resident responded well to the Narcan. The report indicated that the resident admitted he/she had taken dope that a friend brought in the day before but would not reveal the friend's name. In response to this incident Resident #149 was to receive all visits in the front lobby of the facility. The facility reviewed the visitors from the previous day and a specific visitor was banned from further visits.
Staff #65 a receptionist was interviewed on 12/11/19 at 11:30 AM. She explained when visitors sign in, they are required to have their photo ID scanned into the system and kept on file. Their information and photo pops up on the screen and is flagged to indicate they may not visit if they've been banned.
Review of Resident #149's medical record revealed the resident had a history of substance abuse. Resident #149 was involved in a Wellness Program for substance abuse at the facility and had an order for Methadone daily for substance abuse. Methadone is an opioid medication used to prevent withdrawal symptoms caused by stopping other opioids.
A plan of care was developed on the day of the incident for: Risk for substance abuse. The resident's goal: will have no further episodes of consuming illegal substances. The interventions included: Report to nurse/NP(nurse practitioner)/MD(physician) immediately any signs of illicit drug use/abuse; Resident may only receive visits in the front lobby for all visits. Observe for signs/symptoms of withdrawal. Reinforce the residents need for a plan for recovery and sobriety as a means of improving judgement and behavioral self-control to reduce the probability of relapse.
The facility staff failed to include the residents involvement in the Wellness program, that a particular visitor was banned, that Resident #149 was receiving methadone for substance abuse nor how staff were to reinforce his need for a plan for recovery and how they would assist him in improving judgement and self-control. The plan did not include objectives staff were to measure to determine the resident's progress or lack of progress toward reaching his/her goal.
The facility Administrator was made aware of the above findings on 12/11/19 at 2:54 PM.
3c) Resident #4's medical record was reviewed on 12/3/19 at 2:19 PM. Review of the resident's plan of care revealed: Resident exhibits or is at risk for gastrointestinal (GI) symptoms or complications related to colostomy/ileostomy, chronic constipation. The resident's goal was: Will be free of GI complications. The plan did not include measurable objectives designed to meet the resident's goal.
A plan of care: requires extensive assistance for mobility related to: paraplegic condition and contractions of LE (lower extremities). The Resident's goal: will utilize ¼ bed rail(s) for extensive assistance (for turning and re-positioning) while in bed x 90 days.
The plan did not include measurable objectives designed to meet the resident's goal.
The interventions were:
Assess and monitor residents need for bed rails. Provide resident with bed rails to assist with mobility.
The plan failed to identify Resident #4's mobility needs and care to be provided to meet his/her needs including what is meant by extensive assistance, the resident's mobility needs when out of bed, transferring, number of staff required and if assistive devices are used by the resident.
The facility developed 20 plans of care for Resident #4, 16 of the plans failed to include measurable objectives to meet each specific resident goal or reflect interventions designed to enable the resident to meet his/her objectives.
Review of facility documentation on 12/9/19 revealed Resident #4 was found unresponsive in bed and Narcan was administered and the resident came back to baseline orientation. Narcan is an opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression.
Review of Resident #4's medical record revealed that a care plan was initiated for substance use related to history of addiction which stated, is at risk for substance use (drugs) related to a history of addiction which was initiated on 9/23/19 and updated on 10/14/19. The goal, resident/patient acknowledges addiction and the negative effect of chemical use on functioning and relationships by next review with the (3) interventions: monitor conditions that may contribute to substance use, monitor medications for potential contribution to substance use and/or drug interaction side effects, and evaluate need for Psych/behavioral health consult. The care plan was not comprehensive as it did not have specific resident centered interventions.
On 12/11/19 at 11:08 AM the care plan was reviewed with Nursing Home Administrator, Staff #3 who confirmed the lack of a comprehensive care plan.
3d) Review of the medical record for Resident #122 on 11/26/19 revealed documentation that the resident was admitted on [DATE] and discharged on 7/15/19. The resident was a bilateral below the knee amputee (BKA) and had an open wound on the right stump which required wound dressing changes.
Interview of the complainant on 11/26/19 at 10:41 AM revealed the resident advised him/her that the resident had a wheelchair but the home he/she was discharged to was not wheelchair accessible and the resident did not have a ramp to get into the home. The resident informed the complainant that the facility discharged him/her in a cab, and he/she had to crawl up the stairs to get into the house and the cab driver took the wheelchair up the steps for the resident.
A 7/15/19 social service note documented she met with the resident upon discharge order. The social work note documented that the resident could bump up the stairs. The note continued, met to discuss post discharge care arrangement. His/her primary concern was how he/she would enter his/her home. SW (social work) relayed answer given by rehab. His/her grandmother was also concerned about it and phoned in. Another concern she voiced was why she was not involved in care planning or this discharge discussion.
Review of the care plan, resident has potential for discharge or is expected to be discharged r/t desire to discharge to community had a goal, will have an ongoing d/c plan that provides for a safe and effective discharge that was initiated on 6/3/19 and canceled on 6/25/19. There was no active care plan at the time of discharge for discharge planning.
3e) Review of Resident #123's medical record on 11/26/19 revealed an MDS assessment with an assessment reference date of 3/14/19, Section H, urinary incontinence which documented the resident was frequently incontinent. The facility failed to initiate a care plan for urinary incontinence.
On 12/2/19 at 2:02 PM interview with the Director of Nursing (DON) confirmed there was no care plan for urinary incontinence.
3f) Review of Resident #36's medical record on 12/5/19 revealed the resident was admitted on [DATE] from an acute care facility. The discharge summary from the acute care facility on 9/8/19 documented that the resident had multiple wounds on the back.
A skin integrity sheet was started on 9/17/19 for a rash on the mid back, abdominal folds and back of knee. A second skin sheet was started for a skin tear on the mid back and a third skin sheet was for an abscess on the lower back. There was no buttock skin sheet. The abscess notes of 11/15/19 documented a stage 2 on the sacrum, a lower back wound and notes documented that the wounds were improving. There was no further documentation on skin sheets which tracked the progress of the skin integrity. There was no skin sheet for the stage 2 on the sacrum.
A care plan, resident at risk for skin breakdown related to surgical/ulcer and has actual skin breakdown type: surgical, ulcer, rash had the goal the resident's wound/skin impairment will heal as evidenced by decrease in size, absence of erythema and drainage and or presence of granulation. An intervention on the care plan, weekly wound assessment to include measurements and description of wound status was created on 9/17/19. The care plan was not followed as weekly wound assessments to include measurements and description of the wounds was not done.
An interview was conducted with Certified Registered Nurse Practicioner (CRNP) #35 on 12/5/19 at 12:15 PM who stated, I saw his/her wounds. He/she had candidiasis in the groin area. CRNP #35 stated that the resident had issues with wanting care and that he/she would refuse care. The resident was followed by the wound care CRNP, CRNP #20, and was seen on 9/18/19, 10/16/19, 10/23/19, 10/30/19 and 11/6/19. The only measurements of the wounds were done on the CRNP assessments. The CRNP did not see the resident weekly, therefore skin integrity was not being monitored and documented during the time period when the wound CRNP did not see the wounds.
Discussion was held with the Director of Nursing on 12/5/19 at 3:30 PM who confirmed the lack of skin monitoring, therefore not following the care plan.
2) Review of Resident #12's medical record revealed the resident was cognitively intact with adequate hearing and speech for communication. The resident has had a diagnosis of sleep apnea since October 2017 and had orders for a Bilevel Positive Airway Pressure (BiPAP) machine in March of 2018. In August of 2018 the resident had an order for BiPAP to be used at bedtime. Review of the Transfer Form for a hospitalization in August 2018 revealed a Continuous Positve Airway Pressure (C-PAP) machine had been sent to the hospital with the resident. Further review of the medical record revealed that on 8/16/18 the BiPAP order was discontinued with the following notation in the orders: re-admitted .
BiPAP is Bilevel Positve Airway Pressure. A BiPAP machine includes a mask or other device that fits over the nose and mouth and straps into position, a tube that connects the mask to the machine that blows air into the tube. CPAP is Continuous Positve Airway Pressure. A CPAP machine is similar to a BiPAP machine in that both machines deliver pressurized air through a mask to a patient's airway.
There were no active orders for the use of a BiPAP machine since August 2018. On 12/4/19 at 3:37 PM the Director of Nursing reported that the resident went to the hospital (in August 2018) and the order just did not get put back on (upon re-admission).
Further review of the medical record revealed a Care Plan Meeting note dated 8/26/19 that included the following: Does not use CPAP consistently despite sleep apnea. Further review of this note revealed unit nurse manager #5 had attended the care plan meeting.
On 12/5/19 at 9:55 AM unit nurse manager #5 reported, in regard to her attendance at the August 2019 care plan meeting, that Resident #12 was not on her unit but that she may have been covering for the other unit manager. She went on to report that she does know some about the resident but was unsure about the use of a CPAP for the resident. After review of the Care Plan Meeting note the unit nurse manager #5 reported in regard to the CPAP: if [resident] was on my floor I would have followed-up.
Further review of the medical record failed to reveal documentation that a care plan addressing the resident's sleep apnea, or the use of the BiPAP machine, had been developed, implemented or discontinued.
Based on observations, record reviews, and staff interviews, it was determined that the facility failed to develop plans of care that were resident specific and included measurable objectives and goals related to positioning (Resident #104), respiratory care (Resident #20), sleep apnea (Resident #12). The facility failed to develop and implement comprehensive resident centered care plan with measurable objectives for Resident #58, Resident #4, Resident #149, Resident #122, Resident #123, Resident #36, and Resident #42. The facility failed to follow a resident ' s care plan and failed to develop and implement comprehensive person centered care plans with measurable goals and objectives for ADLs (Resident #32, Resident #19 and Resident #10), and hospitalization (Resident #13 and Resident #14). Finally, the facility failed to develop and implement a comprehensive resident centered care plan for a resident receiving dialysis (Resident #114). Total sample 104.
The findings include:
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
1a) Resident #104's medical record was reviewed on 11/19/19. The record review revealed a plan of care focus/concern, for Resident is at risk for decreased ability to perform ADL's (activities of daily living) related to recent CVA (stroke) and limited mobility. This care plan focus area was initiated on 11/13/18 and the goal was written as Resident will maintain highest capable level of ADL ability x 90 days. This goal was not measurable. Review of the most recent comprehensive assessment dated [DATE], revealed that Resident #104 was dependent on staff for care, safety and comfort. The only intervention indicated to monitor conditions that may contribute to ADL decline, including metabolic causes . The one intervention to meet stated goal did not indicate how the resident would improve or what interventions to provide related to providing ADL care to Resident #104.
Another care plan focus area for Resident #104 was initiated on 11/13/18 as the resident has a diagnosis of diabetes: Insulin Dependent. The record revealed that the resident was not insulin dependent as s/he has not received any insulin since 9/1/19. Prior to 9/1/19 the resident's blood sugar level was checked weekly and occasionally the resident received a sliding scale dose of insulin. The written plan of care was not specific for this resident.
1b) Observation was made of Resident #20 on 11/15/19 at 9:02 AM. Resident #20 was lying in bed; the head of the bed was noted to be approximately at a 45-degree angle. The resident was wearing a nasal cannula (a lightweight tube that is hooked onto an oxygen concentrator that delivers oxygen to a resident who needs respiratory help). The nasal cannula was hooked onto the oxygen concentrator and was delivering 3.0 liters (L) of oxygen. Resident #20 was observed again with a second surveyor at 2:27 PM on 11/15/19 and was receiving oxygen at the same rate of 3.0 L.
On 11/15/19 at 2:45 PM, a review of Resident #20's TAR (treatment administration record) revealed an order for oxygen at 2 L/min continuous and was documented as done at that time. The order on the TAR was originally prescribed on 1/18/19.
At 3:19 pm the Director of Nursing (DON) was asked to make a copy of Resident #20's November 2019 TAR. Upon receipt of the copied TAR the DON was advised of the incorrect oxygen flow and failure of the staff to accurately document oxygen administration.
Review of Resident #20's written care plans on 11/20/19 revealed a plan of care with a focus area for Resident exhibits or is at risk for respiratory complications related to COPD (chronic Obstructive Pulmonary disease). There was only one intervention written; O2 as ordered via nasal cannula. The facility had failed to follow/implement the plan of care for Resident #20.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
5d) On 12/3/19 at 12:39 PM, review of Resident #10's medical record revealed the resident had severe cognitive impairment, impaired mobility and dependent for all ADLS (activities of daily living). Re...
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5d) On 12/3/19 at 12:39 PM, review of Resident #10's medical record revealed the resident had severe cognitive impairment, impaired mobility and dependent for all ADLS (activities of daily living). Review of Resident #10's care plans revealed a care plan Resident is dependent for all ADL's and mobility that had the goal Resident's ADL care needs will be anticipated and met throughout the next review period x 90 days. Review of Resident #10's medical record failed to reveal evidence the care plan had been reviewed after the resident's most recent quarterly assessment with a reference date of 8/17/19. There was no documentation to indicate the resident's progress or lack of progress towards his/her goal had been evaluated and the facility failed to reveal evidence the care plan had been updated based on the needs of the resident or in response to current interventions
Continued review of Resident #10's care plans revealed a care plan, Resident has stage 4 to right buttocks, indicating the resident had a Stage 4 pressure ulcer. (bed sore; caused by unrelieved pressure, staged according to the severity) (Stage 4 ulcers are the most serious; extend below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments), with the goal, wound will show improvement AEB (as evidenced by) no s/s (signs/symptoms) of infection. Review of Resident #10's medical record revealed, in a 9/4/19 care plan evaluation, the nurse wrote care plan reviewed and updated; the resident was seen on wound rounds this AM; no new orders continue with plan of care. The care plan evaluation did not measure the residents progress or lack of progress toward reaching his/her goals, did not reflect that the facility reassessed the effectiveness of the approaches or updated the care plan based on the needs of the resident.
5e) On 12/5/19 at 9:00 AM, review of Resident #14's medical record revealed the resident had a suprapubic catheter (hollow tube used to drain urine inserted in the bladder through an incision in the belly) for a neurogenic bladder (bladder dysfunction) and a history of recurrent UTIs (urinary tract infections). The medical record documented Resident #14 had a urine c/s (culture & sensitivity) (test for bacteria and susceptible antibiotic) which reported on 8/1/19 that Resident #14 had a UTI. The resident's medical record documented Resident #14 was hospitalized in mid-August 2019, treated for a UTI and returned to the facility. On 8/16/19, in a hospital discharge summary, the physician documented Resident #14's diagnosis included suprapubic catheter associated UTI which was treated with IV antibiotics. Resident #14's August 2019 MAR (medication administration record) documented the resident received Ampicillin (antibiotic) by mouth on 8/1/19 and 8/2/19 for UTI, and the antibiotic Ertapenem (Ivanz) intravenously (IV), on 8/17/19 thru 8/20/19) for treatment of UTI.
Review of Resident #14's care plans revealed a care plan, Resident requires a supra-pubic cath (tube used to drain urine that is inserted in the bladder through an incision in the belly) r/t (related to) neurogenic bladder (bladder dysfunction) with the goal Resident will have no signs and symptoms of urinary tract infection x 90 days. There was no evidence in the medical record that the care plan had been evaluated following the resident's quarterly assessments with an assesssment reference date (ARD) of 8/18/19 and an ARD of 8/28/19. On 9/6/19 at 10:04 AM, in a care plan evaluation note, the nurse wrote that the care plan was reviewed and updated, the resident continued to require the suprapubic catheter, continued cranberry tablets for preventative maintenance, and continue with the plan of care and interventions. The care plan evaluation did not measure the residents progress or lack of progress toward reaching his/her goals, did not reflect that the facility reassessed the effectiveness of the approaches or updated the care plan based on the needs of the resident.
Continued review of Resident #14 care plans revealed a care plan, Resident is at risk for UTI r/t chronic S/P (suprapubic)use d/t (do to) neurogenic bladder with the goal Resident's UTI will be resolved s/p (status post) po (by mouth) ABT (antibiotic) therapy. The date initiated was 3/18/19 for the care plan focus, goal and interventions with a goal revision date of 9/19/19. There was no evidence in the medical record that the care plan had been evaluated following the resident's quarterly assessments with an ARD of 8/18/19 and an ARD of 8/28/19. In a care plan evaluation note on 9/6/19 at 9:54 AM, the nurse documented that the care plan was reviewed and updated, the resident continued to be high risk for UTI's related to the suprapubic catheter and to continue with plan of care and interventions. The evaluation did not evaluate the resident's progress or lack of progress towards his/her goal or if the goal continued to be appropriate and failed to reveal evidence the care plan had been updated based on the needs of the resident or in response to current interventions.
The Director of Nurses was made aware of the above findings on 12/6/19 at 2:29 PM
5c) Resident #71's record was reviewed on 11/26/19 at 2:58 PM. The resident had a physician's order for Ativan 1 mg (milligram) give 1 tab by mouth three times a day for anxiety. Ativan is a psychotropic antianxiety medication. The Ativan was decreased on 10/7/19 to 1 mg twice a day to attempt a gradual dose reduction (GDR). A progress note written on 10/8/19 by Staff #21 a Certified Registered Nurse Practitioner (CRNP) indicated the resident reported that Resident #71 was not tolerating the reduction and was having increased anxiety which was affecting his/her breathing.
The Ativan was increased back to 1 mg three times a day on 10/8/19. Resident #71's plan of care included but was not limited to: risk for complications related to the use of psychotropic drugs. The resident's goal: will have the smallest most effective dose without side effects x 90 days. Interventions included: Gradual dose reduction as ordered. Resident #71's plan of care was not updated to reflect interventions to implement the GDR nor did it reflect that a GDR was attempted and failed.
The Director of Nursing was made aware of these findings on 12/3/19 at 2:17 PM.
Based on observation, record review and interview it was determined that the facility failed 1) to revise a resident's care plan for activity pursuits after the completion of the comprehensive assessment (Resident #110). This was found to be evident for 1 out of 7 resident's reviewed for activities; 2) to ensure documentation of an explanation of why a resident or the resident's representative was unable to participate in the development of the care plan (Resident #12 and #82). This was evident for 2 out of 5 resident's reviewed for care planning; 3) to ensure communication between disciplines in regard to care plan meeting participation as evidenced by failure to have a system in place to ensure social work, who notifies disciplines of upcoming care plan meetings, was aware when a resident was currently receiving therapy services (Resident #82). This was evident for 1 of 8 residents reviewed for Activities of Daily Living.; 4) to ensure care plan meeting occurred to review and revise the care plan after the quarterly Minimum Data Set assessment (Resident #84); 5) perform appropriate revisions to the care plan interventions as resident care needs became apparent or changed over time, and failed to thoroughly evaluate/review and revise resident plans of care after each assessment. This was evident for 2 of 5 residents (Resident #101 and #43) reviewed for care planning and 1 of 7 residents (Resident #71) reviewed for unnecessary medication review and for 2 of 2 residents (Resident #14, #10) reviewed for hospitalization.
The findings include:
1) Review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive and lung disease. The resident is unable to independently ambulate and requires extensive assistance of staff for bed mobility, dressing, eating and personal hygiene. The resident has severe cognitive impairment and unclear speech.
On 11/20/19 review of the residents care plan addressing activities revealed the following goal: will consistently accept and utilize adaptations and modifications to enable participation in activities of interest through next review date. This plan was initiated in 2018 with a revision date of 11/18/19. The only intervention included in this care plan is: Establish a relationship with [name of resident] using one-to-one interventions, informal conversations and to foster trust and an environment where [he/she] feels comfortable to express [his/her] interest in activities. This intervention was initiated in 2018.
On 11/21/19 at 3:30 PM the activity director #14, after review of the care plan, indicated the plan was appropriate for the resident since the resident does receive one to one room visits. She went on to report that it is the resident's preference not to attend large or small group activities and that activity aide #60 provides the resident hand massages. Surveyor then requested documentation of activity services provided to residents.
On 11/21/19 at 4:52 PM interview with activity aide #60 revealed she visits the resident a couple times a week, she does massage the resident's hand with lotion and attempts to have conversations with the resident but the resident usually only responds with yes or no and that resident enjoys having spiritual text read to him/her. The aide also reported the resident sleeps often and stated: I have instructions not to wake [the resident].
Review of the 10/28/19 Recreation Comprehensive Assessment completed by activity aide #60 revealed the resident is seen weekly for room visits for sensory stimulation, looks at the television, listens to music and makes some eye contact to picture flash cards, receives massaging hands with lotion, enjoys staff spiritual reading and will sit in the day room watching television.
On 11/22/19 at 3:34 PM surveyor reviewed the concerns with the Activity Director that the care plan failed to address the items that were included and documented in the assessment completed by the activity assistant.
2) Review of Resident #12's medical record revealed the resident was cognitively intact with adequate hearing and speech for communication. On 11/15/19 at 9:42 AM the resident denied knowledge of care plan meetings.
Further review of Resident #12's medical record revealed in the Care Plan Meeting notes for 5/30/19 and 8/26/19 in the section for Family/resident in attendance: No reply to invite is all that was documented.
Further review of the medical record on 12/5/19 revealed a Care Plan Meeting note dated 11/26/19. In the section of this note for Family/resident in attendance: No is all that was documented. No documentation was found as to why the resident did not attend the care plan meeting.
3) Review of Resident #82's medical record revealed the resident was cognitively intact with adequate hearing and speech for communication. On 11/15/19 at 1:20 PM the resident denied knowledge of a Care Plan Meeting.
On 11/19/19 at 12:21 PM review of the medical record revealed a care plan meeting note dated 11/19/19. In the section for Family/resident in attendance: No reply to invite is all that was documented. Review of the August 2019 care plan meeting note also revealed the no reply to invite statement.
On 11/19/19 at 2:33 PM the social worker #9 reported that for resident's that are able to participate in their care plan meetings she will hand deliver an invitation to he meeting. She went on to report that if the resident is not present in the room she will leave the invitation on the side side table or the bed so the resident will see it. Surveyor then reviewed the concern that the resident denied knowledge of the care plan meeting.
On 11/19/19 at 4:26 PM surveyor reviewed with social worker that documentation of no reply to invite does not address why the resident was unable to participate in the care plan meeting.
On 11/19/19 further review of Resident #82's medical record revealed the resident was currently receiving skilled occupational therapy services. No documentation was found to indicate a representative from therapy attended the 11/19/19 care plan meeting.
On 11/19/19 at approximately 2:30 PM the social worker confirmed that no representative from therapy attended the resident's care plan meeting that occurred earlier in the day. The social worker went on to report that she was not aware that the resident was currently receiving therapy.
On 11/19/19 at 2:44 PM the therapy director #16 confirmed that the resident was currently on case load and reported she was just on the phone with the social worker about coming up with a plan and that the social worker will be emailing the therapy director a list of residents with care plan meetings coming up so she can attend the meetings.
On 11/19/19 at 3:30 PM surveyor reviewed the concern with the Director of Nursing that a care plan meeting was conducted without input from therapy department for a resident currently receiving therapy services.
4) Review of Resident #84's medical record revealed the resident has mild cognitive impairment but adequate hearing and speech for communication and adequate decision making capacity to make health care decisions.
On 12/3/19 review of the medical record revealed a care plan meeting note dated 7/29/19. In the section for Family/resident in attendance: No reply to invite is all that was documented.
Further review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/23/19 had been completed by staff. Further review of the medical record failed to reveal documentation that a care plan meeting had occurred after the completion of the 10/23/19 MDS assessment.
Review of a Care Plan Reviews Due Report provided by the SW #9 during the survey revealed a list of residents with Review (ARD) Dates from 10/22/19 through 11/21/19. Resident #84's name did not appear on the report.
Review of copy of the resident's care plan provided during the survey revealed a notation Last Care Plan Review completed: 11/6/2019 however review of the goals included in this care plan revealed target dates of 10/20/2019. No documentation was found that any revisions had been made to the care plan since the 10/23/19 MDS assessment.
5a) Resident #101's medical record was reviewed on 12/3/19. A plan of care was developed on 8/14/18 for Resident has actual skin breakdown r/t chronic venous wound to right medial leg. The goal was written as the resident's wound will heal as evidenced by decrease in size, absence of erythema and drainage and presence of granulation x 90 days. The plan included 7 interventions. The plan of care evaluation note dated 9/5/19 stated Resident seen by wound center for Unna Boot weekly, will continue plan of care goals. There was no documentation to indicate that the staff evaluated the wound toward the progress of stated goal. The intervention to attend weekly wound clinic and the application of Unna boot was not identified as interventions for reaching the stated goal. On 9/5/19 the resident had missed 3 weekly wound clinic appoints. This was reviewed with the Unit manager #5 on 12/04/19 at 11:14 AM.
Cross Reference to F684 Resident #101.
Further review of Resident #101's medical record revealed in the Care Plan Meeting note for 12/2/19 in the section for Family/resident in attendance: No is all that was documented. No documentation was found as to why the resident did not attend the care plan meeting.
5b) Resident #43's medical record was reviewed on 12/11/19 as part of a follow-up to a facility reported incident of the resident being found to be smoking in the building. Review of the care plans revealed a focus area for allowing the resident to smoke with supervision per smoking assessment. The care plan was shown to not have been updated since it was initiated on 6/13/19. The target date written as 6/20/19 to meet the goal of patient will smoke safely x 90 days per smoking assessment. One of the interventions was listed as maintain smoking materials at nurses' station. Interview of the unit manager #5 at 2:13 PM on 12/11/19 revealed that the smoking materials were kept at the reception desk on the first floor. The unit manger acknowledged that the care plan was incorrect and had not been updated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview it was determined that the facility failed to meet the professio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview it was determined that the facility failed to meet the professional standards of quality by failing to administer ordered medications to a resident for 23 days. This was evident for 1 of 8 residents (Resident #99) reviewed for pharmacy reviews.
The findings include:
A medical record review on 11/15/19 at 11:00 AM, revealed an admission history and physical completed by Certified Registered Nurse Practitioner (CRNP) #21 on 10/23/19, which documented that Resident #99 was admitted due to a right knee prosthetic joint infection to continue Intravenous (IV) (directly in the vein) antibiotics and rehabilitation. She noted in this document that the resident was receiving Triumeq to treat Human Immunodeficiency Virus (HIV).
In addition, review of the Physician Order Summary for October 2019, revealed the resident had an order for Triumeq (Abacavir, Dolutegavir, Lamivudine) 600-50-300 mg dated 10/22/19 to be given 1 time a day.
Review of the Medication Administration Record (MAR) for October 2019, revealed the following:
10/27/19, it was documented administered by Licensed Practical Nurse (LPN) #6
10/28/19, it was documented administered by Nurse Practice Educator (NPE) Registered Nurse (RN) #4.
10/29/19, it was documented administered by Register Nurse (RN) #48
10/30/19, it was documented administered by RN #48
10/31/19, it was documented administered by LPN #6
In addition, review of the physician's progress notes dated 10/23/19 and signed by CRNP #21, 10/24/19 signed by attending physician #44, and 10/25/19 signed by CRNP #35 revealed documentation that the attending physician and CRNPs thought the resident was receiving Triumeq.
Review of the MAR for November 2019, revealed the following:
11/2/19, it was documented administered by LPN #49
11/3/19, it was documented administered by RN #50
11/5/19, it was documented administered by LPN #40
11/7/19, it was documented administered by LPN #51
11/8/19, it was documented administered by LPN #40
11/9/19, it was documented administered by RN #52
Review of the progress notes dated 10/22/19 through 11/13/19, revealed no documentation that the physician was made aware of the medication not being available for the resident.
During an interview with Resident #99 on 11/15/19 at 10:29 AM, the resident reported that he/she had not had their Triumeq since being admitted to the facility on [DATE] until yesterday (11/14/19). The resident reported speaking with various nurses and a supervisor regarding this issue and was told his/her insurance would not cover the medication. He/she stated I told them to call my doctor at [acute care facility] to get the medication.
On 11/20/19 at 11:17 AM, review of the facility's pharmacy receipt log for 10/2019 and 11/2019, revealed that the Triumeq was not dispensed to the facility until 11/13/19. In addition, review of facility's medication list available in the drug storage box revealed that the Triumeq was not kept on hand in the facility. This confirmed that Resident #99 went 23 days without his/her Triumeq. However, 4 Registered Nurses and 4 Licensed Practical Nurses signed the medication as being administered and some signed more than one time over a 21 day period.
During an interview with the DON on 11/20/19 at 12:43 PM, she confirmed the medication was not sent from another pharmacy. She was made aware that facility staff had been signing that it was administered during the time it was not available from the pharmacy.
An interview on 11/20/19 at 2:04 PM, with the Assistant Director of Nursing (ADON) #15, revealed that she was aware of the non-covered medication for Resident #99 and once she informed RN #39, who was an agency nurse, and the DON about the issue she failed to follow-up to ensure this resident had all of his/her ordered medications. She stated that she heard nothing more from her staff and assumed it was taken care of even though she was the acting Unit Manager for the unit in which Resident #99 resided.
A subsequent interview with the DON on 11/20/19 at 2:29 PM, revealed she was informed by Resident #99 that he/she was missing Triumeq since being admitted to the facility. However, she reported that she did not investigate the issue or follow-up with the resident.
During an interview with Nurse Practice Educator (NPE) RN #4, who was one who signed the medication as being administered, on 11/21/19 at 11:26 AM, he confirmed that he had mistakenly signed the Triumeq as being administered to Resident #99 on 10/28/19.
An interview with LPN #6, who had signed the medication as being administered, revealed the resident had talked to her about the missing Triumeq, but she could not remember the exact date. Stated she mistakenly signed it off as being administered on 10/27/19 and 10/31/19.
During an interview with CRNP #21 on 11/21/19 at 1:12 PM, via a phone call, revealed she was not aware the medication was not being administered to Resident #99.
An interview with Resident #99's attending Physician #44 on 11/22/19 at 10:20 AM, via a phone call, he confirmed he was not aware the resident was not receiving the Triumeq since admission until after surveyor intervention on 11/21/19.
On 11/21/19 at 11:36 AM, the Director of Nursing, Administrator, Staff #2 and Administrator, Staff #3 were informed of the concerns.
Cross Reference: F580, F684, F755, F760, and F842
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident #71's record on 12/3/19 at 9:37 AM revealed a plan of care for: potential for discharge or is expected to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident #71's record on 12/3/19 at 9:37 AM revealed a plan of care for: potential for discharge or is expected to be discharged , related to: 1) Resident's desire to discharge to community, Waiver candidate. 2) MDH (Maryland Department of Health) denied LOC (level of Care) for continued SNF (skilled nursing facility) coverage. The resident's goal was: Resident will have an ongoing discharge plan that provides for a safe and effective discharge. The interventions were:
i) Inform IDT (interdisciplinary team) members and physician/mid-level practitioner of resident/patients desire to be discharged .
ii) Make referrals to community-based agencies, providers and services communicating the resident/patients' needs and barriers to care.
iii) Refer to MFP to seek additional support system and funding.
iv) Arrange for all needed equipment prior to discharge. Needs include: wheelchair or walker as indicated.
A Care Plan Evaluation progress note dated 9/19/19 by Staff #9 Social Services Specialist indicated while the resident voices his/her desire to transition back, he/she does not feel ready to do so. He/She shows no interest in applying for waiver. SW (Social Worker) assisted him/her to request an administrative hearing to appeal MD DoH (Maryland Department of Health) decision to deny his/her LOC (Level of Care).
Staff #9 was interviewed on 12/3/19 at 1:44 PM and was asked about Resident #71's discharge plan. She indicated that Resident #71 plans to go home with his/her sister when his/her waiver is approved, that he/she had a pending administrative hearing and that a referral was made to legal aide.
The care plan was not updated nor revised in the past year to reflect/include the pertinent discharge planning interventions and progress identified during the interview with Staff #9 and in her progress note.
The facility failed to develop and implement a comprehensive resident centered discharge care plan that identified the resident's needs, failed to re-evaluate and modify the discharge plan to reflect changes in the resident's needs and in response to information from referrals to local contact agencies.
The Director of Nursing was made aware of these concerns on 12/6/19 at 11:07 AM.
Based on a complainant interview, medical record review and staff interview it was determined the facility failed to safely discharge a resident and failed to: 1) develop an individualized discharge plan/care plan for a resident admitted to the facility for short term rehabilitation. This was evident for 1 of 4 residents (Resident #122) reviewed for discharge; 2) ensure a resident's discharge plan included all pertinent resident information. This was evident for 1 of 7 residents (Resident #71) reviewed for unnecessary medication.
The findings include:
1) Review of the medical record for Resident #122 on 11/26/19 revealed documentation that the resident was admitted on [DATE] and discharged on 7/15/19. The resident was a bilateral below the knee amputee (BKA) and had an open wound on the right stump which required wound dressing changes.
Interview of the complainant on 11/26/19 at 10:41 AM revealed the resident advised her that he/she had a wheelchair but the home he/she was discharged to was not wheelchair accessible and he/she did not have a ramp to get into the home. The resident informed the complainant that the facility discharged him/her in a cab, and he/she had to crawl up the stairs to get into the house and the cab driver took the wheelchair up the steps for the resident.
A 7/15/19 social service note documented they she met with the resident upon discharge order. The social work note documented that the resident could bump up the stairs. The note continued, met to discuss post discharge care arrangement. His/her primary concern was how he/she would enter his/her home. SW (social work) relayed answer given by rehab. His/her grandmother was also concerned about it and phoned in. Another concern she voiced was why she was not involved in care planning or this discharge discussion.
Review of the care plan, resident has potential for discharge or is expected to be discharged r/t (related to) desire to discharge to community had a goal, will have an ongoing d/c (discharge) plan that provides for a safe and effective discharge that was initiated on 6/3/19 and canceled on 6/25/19. There was no active care plan at the time of discharge for discharge planning.
Physical Therapist (PT) #33 was interviewed on 11/16/19 at 11:30 AM and stated that the resident was a bilateral amputee. She stated that PT picked the resident up in case load for transfers to be independent from bed to wheelchair. PT #33 stated that the resident previously had a prosthesis which he/she did not bring to the facility and that the right BKA had a wound, so it wasn't ready for a fitting. The resident was discharged from therapy at an independent level with transfers at wheelchair level. PT #33 stated, while in the building I encouraged him/her to do a walk out to maintain strength and endurance until ready for fitting of right leg, however we didn't get to that level due to discharge. PT #33 stated that the resident was discharged from therapy and remained in the facility. He/she wasn't able to go up steps here because the right stump wound was fresh and in a situation like that, he/she could bump up and down on his/her butt if the stump was healed. I don't know if his stump was healed. I don't believe it was healed. When asked how he/she was to go up and down the steps if the stump wasn't healed, she said, he/she was still in the building but discharged from therapy. I did not discharge him/her home. It would not be good if his/her stump wasn't healed. It would have been more appropriate for him/her to be discharged home on a level floor home without steps. He/she was sort of in and out of compliance because other things are more important than therapy such as smoking or talking to other people. We often offer and bring up about offering another place, but we have no recollection of doing that.
Social Worker (SW) #9 was interviewed on 11/26/19 at 12:59 PM and stated, We do not do home evaluations. We don't have personnel to do a home evaluation. We do references to do home health and DMEs (durable medical equipment). She continued, the medical provider with the resident initiated the discharge. The resident stated his/her grandmother and friends would help him/her at home and stated that he/she had friends that could help him/her get in and out of the house. I cannot see that he/she did not say if he/she could get up the steps. The SW continued, based on the medical provider's note the resident chose to be discharged . The IDT (interdisciplinary team) would meet and talk about discharge. I can't say there was a meeting with all of use to discuss how the resident would get home with no lower legs. The surveyor asked if the option of going somewhere else that had only one floor was brought up to the resident. The response was, discharge planning is as needed or per request. We have care plan meetings; IDT meeting and social workers often meet formally or informally to talk about how things are going.
The Director of Nursing (DON) was interviewed on 11/27/19 at 7:10 AM and stated, therapy said he/she could bump up and they worked on that with him/her in the facility. The surveyor advised that therapy stated only if the stump was healed and the DON stated, Oh, I didn't know that.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
2a) On 11/18/19 at 9:19 AM, Resident #19 was observed to have different lengths of facial hairs above the resident's upper lip and on the resident's chin. On 11/20/19 at 11:04 AM, an observation of Re...
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2a) On 11/18/19 at 9:19 AM, Resident #19 was observed to have different lengths of facial hairs above the resident's upper lip and on the resident's chin. On 11/20/19 at 11:04 AM, an observation of Resident #19 was made by 2 surveyors and revealed the resident continued to have facial hair of varying lengths above the resident's upper lip and on his/her chin.
On 11/20/19 at 11:07 AM, Resident #19's medical record was reviewed. Resident #19's most recent assessment with a reference date of 9/11/19 documented that Resident #19 was severely cognitively impaired and dependent on staff for extensive assistance with all ADLs, including personal hygiene. Review of Resident #19's care plans failed to reveal a comprehensive care plan had been developed to meet Resident #19's ADL needs.
On 11/21/10 at 9:00 AM, and again at 11/21/19 at 12:22 PM, an observation was made of Resident #19. On each of these observations, Resident #19 was observed to have unshaved facial hair. Continued review of the medical record failed to reveal documentation to indicate Resident #19's facial hair was not shaved by the facility staff. Staff #8, the Unit Manager, was made aware of these findings on 11/21/19 at 2:50 PM. At that time, when asked why Resident #19 was not being shaved, Staff #13 stated he/she did not know.
2b) On 11/18/19 at 12:48 PM, an observation was made of Resident #10, in bed, being shaved by a visitor identified as a family member. During an interview, Resident #10's family member stated that when family members comes to the facility, they will shave the resident, and he/she was concerned that the resident does not get shaved when the family does not come in. The resident's family member also stated that the resident never gets a shower and the resident and family would like the resident to get a shower.
On 12/2/19, at approximately 3:00 PM, during an interview, when asked how he/she would know to give a resident a shower, GNA #72 stated he/she would look in the shower book, and check for the resident room number. Review of the shower book revealed each resident's room number is scheduled for a shower two times a week and indicated Resident #10's room was scheduled for a shower on Tuesday 7-3 and Friday 3-11. When asked if Resident #10 was given showers, Staff #72 stated he/she didn't know because this was the first time the GNA worked with the resident.
On 12/3/19 at 12:39 PM, review of Resident #10's medical record revealed the resident had severe cognitive impairment and impaired mobility and dependent for all ADLS. Review of Resident #10's most recent assessment with a reference date of 8/17/19, documented the resident required extensive assistance for hygiene and was totally dependent on staff for bathing. Review of Resident #10's November 2019 GNA documentation in the electronic medical record revealed the intervention/task for personal hygiene, which included all aspects of personal hygiene, except for bathing and showers, was documented as being done every day in November 2019, however, the task documentation did not differentiate the personal hygiene the resident received, specifically, if the resident had been shaved. Review of the GNA documentation for bathing, revealed Resident #10 received bed baths but failed to reveal documentation that Resident #10 had received any showers. Continued review of the medical record failed to reveal documentation to indicate a shower had been provided or had been offered to the resident.
On 12/4/19 at 2:50 PM, an observation was made of Resident #10 in his/her room, lying in bed. At that time the resident was unshaved with a growth of dark facial hair on his/her face. There was no documentation in the medical record to indicate why the resident had not been shaved.
The Administrator, Staff #3, was made aware of the above findings on 12/10/19 at 2:45 PM. On 12/11/19, at approximately 3:00 PM, Staff #3 provided the surveyor with a revised Tub/Shower schedule for Resident #10 that indicated the schedule was added to the GNA tasks.
Based on observation, family and staff interview and medical record review it was determined that the facility failed to: 1) ensure twice weekly showers were offered to residents. This was found to be evident for 3 out of 3 residents (Resident #369, #84 and #27) reviewed for provision of showers; 2) provide the appropriate care for activities of daily living to residents who were totally dependent on staff for all aspects of care. This was evident for 2 of 8 residents (Resident #19 and #10) reviewed for activities of daily living.
The findings include:
ADLs (activities of daily living) are activities that people perform every day such as, getting dressed, taking showers or baths, cooking, and eating.
1a) On 12/2/19 geriatric nursing assistant (GNA) #34 reported that they document showers in the [electronic health record] and on paper documentation as well. GNA #34 also reported that if a resident refuses a shower this information is documented in the electronic health record and they also get the nurse to sign the paper documentation.
Review of the shower schedules revealed each resident is scheduled for a shower two times a week, according to the resident's room number.
Review of Resident #369's medical record revealed the resident had severe cognitive impairment and required extensive assist for bed mobility and dressing, and was totally dependent on staff for bathing. On 12/2/19 review of the November GNA documentation for bathing, found in the electronic health record, revealed daily bed baths were being provided but failed to reveal documentation of a shower having been provided or offered. No documentation was found that the resident refused a shower. Review of the shower book on the resident's unit failed to reveal a shower sheet for Resident #369.
On 12/2/19 at 2:12 PM surveyor informed the Director of Nursing that no shower sheet was found for Resident #369.
1b) Review of Resident #84's medical record revealed the resident required extensive assist by two persons for bed mobility and was totally dependant on staff for transfers in and out of bed, as well as for bathing.
On 12/2/19 review of the Weekly Bath and Skin Report (shower sheet) for Resident #84 revealed documentation of a refusal on 11/4/19. This report was signed by a GNA only, the area for the nurse's signature was noted to be blank. No additional documentation was found on this form to reveal other refusals or provision of showers during November 2019. Review of the November 2019 GNA documentation for bathing, found in the electronic health record, revealed daily bed baths were being provided but failed to reveal documentation of a shower having been provided or offered.
1c) Review of Resident #27's medical record revealed the resident had severe cognitive impairment, required extensive assistance for bed mobility and was totally dependant on staff for bathing and dressing.
On 12/2/19 Review of the Weekly Bath and Skin Report for the month of November revealed documentation on 11/7/19 only. This documentation included a notation of bed bath and was signed by the GNA only. Review of the November 2019 GNA documentation for bathing, found in the electronic health record, revealed daily bed baths were being provided but failed to reveal documentation of a shower having been provided or offered.
On 12/2/19 at 12:39 PM the unit nurse manager #5 confirmed that if a resident refuses a shower the expectation is that the GNA will inform the nurse and will document on the shower sheet and in the electronic health record.
On 12/02/19 at approximately 2:25 PM surveyor reviewed the concern with the Director of Nursing regarding no documentation found of showers being provided for Residents #369, #84 and #27 for the month of November 2019 and also reviewed lack of documentation of refusals. As of time of survey exit on 12/11/19 no additional documentation had been provided in regard to this concern.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a) On 11/18/19 at 12:20 PM, an observation of Resident #32 revealed the resident was wearing an oxygen nasal cannula (NC) tubin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a) On 11/18/19 at 12:20 PM, an observation of Resident #32 revealed the resident was wearing an oxygen nasal cannula (NC) tubing connected to a water bottle which was connected to an oxygen concentrator set at 2.5 LPM (liters per minute). The surface of the oxygen concentrator was very dusty, and the oxygen tubing and water bottle were not labeled with the date initiated.
On 11/22/19 at 3:00 PM, a review of Resident #32's November 2019 TAR (treatment administration record) revealed an order for O2 (oxygen) at 2 LPM via NC continuous every shift for COPD (chronic obstructive pulmonary disease) that was documented as being administered on 11/18/19, 7-3 shift and on 11/22/19 7-3 shift. Also, there was an order: Oxygen tubing change weekly; label each component with date and initials every night shift on Wednesday that was documented as being done on 11/13/19 and on 11/20/19. Review of Resident #32's care plans revealed a care plan: 1) resident exhibits or is at risk for respiratory complication AEB (as exhibited by) COPD & CHF (congestive heart failure), 2) resident is unable to lie flat while in bed that had an intervention O2 as ordered via NC @ 2 LPM.
On 11/22/19 at 3:25 PM, Resident #32 was observed wearing a nasal cannula that was connected to a water bottle connected to an oxygen concentrator set at 2.5 LPM. The oxygen tubing and the humidifier water bottle were not labeled with the date initiated and the concentrator was soiled with dust. The Unit Manager, Staff #8, was made aware of these findings and confirmed the findings at that time.
The facility staff failed to follow the physician orders by failing to label Resident #32's oxygen tubing and water bottle with the date initiated and failing to ensure Resident #32's oxygen rate was set at 2 LPM. The facility staff failed to follow the resident's care plan by failing to ensure the resident's oxygen rate was 2 LPM. The Director of Nurses was made aware of these findings on 11/22/19 at 4:00 PM.
3b) Review of Resident #17's medical record revealed the resident was admitted to the facility in August 2018. Further review of the resident's medical record revealed the resident was hospitalized [DATE] until 9/23/19. Review of the hospital discharge summary revealed the physician documented on 9/23/19 the resident has a history of obstructive sleep apnea (OSA) and had completed a sleep study to evaluate this in the past, though he/she is not on Continuous Positive Airway Pressure (CPAP) at his/her nursing home. Primary team called his/her nursing home to inquire about these records but none were found. It was communicated to the nursing home the importance of CPAP for him/her given his/her heart failure. A CPAP machine uses a hose and mask or nosepiece to deliver constant and steady air pressure and is a common treatment for OSA.
Further review of the Resident #17's hospital discharge instructions dated 9/23/19 revealed an instruction for Adult Sleep Study-Diagnosis and Referral for therapy. Review of the resident's medical record revealed no evidence the resident received a sleep study.
During interview with Resident #17 on 12/5/19 at 10:40 AM, he/she stated he/she always wears a CPAP at the hospital and was supposed to get one on his/her return to the nursing home but it hasn't happened.
Interview with the Director of Nursing on 12/6/19 at 10:48 AM confirmed the facility staff failed to obtain a sleep study for a resident.
BiPAP is Bilevel Positive Airway Pressure. A BiPAP machine includes a mask or other device that fits over the nose and mouth and straps into position, a tube that connects the mask to the machine and a motor that blows air into the tube. CPAP is Continuous Positive Airway Pressure. A CPAP machine is similar to a BiPAP machine in that both machines deliver pressurized air through a mask to a patient's airway.
2a) Review of Resident #12's medical record revealed the resident was cognitively intact with adequate hearing and speech for communication. The resident has had a diagnosis of sleep apnea since October 2017 and had orders for a BiPAP machine in March of 2018. In August of 2018 the resident had an order for BiPAP to be used at bedtime. Review of the Transfer Form for a hospitalization in August 2018 revealed a C-PAP machine had been sent to the hospital with the resident. Further review of the medical record revealed that on 8/16/18 the BiPAP order was discontinued with the following notation in the orders: re-admitted .
No documentation was found in the primary care provider, or nursing notes, as to why the BiPAP order was discontinued. Review of the discharge summary from the August 2018 hospitalization failed to reveal documentation about sleep apnea or the use of a BiPAP machine.
On 11/15/19 at 1:11 PM unit nurse manager #8 reported that the resident had been non-compliant and refused to use the BiPAP so it had been discontinued.
Review of the 2018 Treatment Administration Record (TAR) revealed documentation that the BiPAP was being utilized prior to the hospitalization in August 2018. Review of the TAR for July and August 2018 revealed documentation of only two occasion when the BiPAP was refused. Further review of the progress notes for July and August 2018 failed to reveal additional documentation that the resident had been refusing the BiPAP.
There were no active orders for the use of a BiPAP machine since August 2018.
Further review of the medical record revealed a Care Plan Meeting note dated 8/26/19 that included the following: Does not use CPAP consistently despite sleep apnea.
Further review of the medical record failed to reveal that a care plan had ever been developed to address the resident's sleep apnea and use of a BiPAP machine.
Further review of the August 2019 care plan meeting note revealed unit nurse manager #5 had attended the care plan meeting. On 12/5/19 at 9:55 AM unit nurse manager #5 reported, in regard to her attendance at the August 2019 care plan meeting, that Resident 12 was not on her unit but that she may have been covering for the other unit manager. She went on to report that she does know some about the resident but was unsure about the use of a CPAP for the resident. After review of the Care Plan Meeting note the unit nurse manager #5 reported in regard to the CPAP: if [resident] was on my floor I would have followed-up.
On 11/22/19 at 12:03 PM the resident reported she doesn't use the BiPAP all the time but confirmed that she had used at times during the past six months.
On 12/4/19 at 3:37 PM the Director of Nursing reported that the resident went to the hospital and the order just did not get put back on [upon re-admission]. Surveyor reviewed the concerns that at the resident's August 2019 care plan meeting the fact that the resident had sleep apnea and should be using the BiPAP was discussed but there was no follow-up and that no documentation was found that a care plan had ever been developed to address the sleep apnea and the use of the BiPAP machine. Also reviewed the concern that the resident reported having used the BiPAP during the past six months despite the absence of an order for it's use or for care of the machine.
2b) On 12/5/19 review of Resident #117's medical record revealed the resident was cognitively intact with adequate hearing and speech for communication. The resident has a diagnosis of Chronic Obstructive Pulmonary Disease with shortness of breath or trouble breathing when lying flat. The resident had orders, in effect since 9/13/19, for CPAP for obstructive sleep apnea to be applied at time of sleep and removed in the morning. There were orders to change or clean the intake filter and disposable supplies (e.g. tubing) per manufacturers guidelines or if soiled every day shift. There was a separate, additional order, for this to be completed on an as needed basis.
On 12/5/19 at 10:55 AM interview with Nurse #70 revealed that she was assigned to care for Resident #117 at this time. The nurse was aware that the resident uses a CPAP machine and takes it off in the morning. She reported that on day shift she does not do anything with the CPAP machine in regard to cleaning it. She went on to report that on evening shift she will check the tubes, clean it and put in fresh water. Review of the Treatment Administration Record revealed staff were documenting that the CPAP was being cleaned on day shift. On 12/5/19 at approximately 4:00 PM review of the medical record revealed the order was changed to every evening shift on 12/5/19.
On 12/05/19 at 10:48 AM the resident reported a concern regarding the fit of the face strap used with the CPAP machine. At 10:53 AM, after surveyor reviewed the resident's concerns regarding the face strap with the unit nurse manager #5, the manager reported that the resident had gone out a couple of times for adjustments. During the interview with Nurse #70, she revealed they were attempting to obtain a different mask for the resident.
Further review of the medical record revealed a care plan, initiated 11/15/19, for Resident is at risk for respiratory complications related to COPD, sleep apnea - CPAP/BIPAP. This plan was initiated two months after the current order for the CPAP went into effect. Review of this care plan failed to reveal interventions regarding the use of the CPAP, the maintenance of the CPAP, or addressing the issue regarding the fit of the mask/straps.
The care plan did include the following intervention: Educate resident and/or health care decision maker on respiratory health and trach care. The resident did not have a trach.
Based on observation, medical record review and staff interview it was determined the facility staff failed to: 1a) ensure oxygen was administered at the rate ordered by the physician, 1b) failed to accurately document the resident's oxygen rate in the treatment record, 1c) failed to implement a care plan for a resident with a diagnosis chronic obstructive pulmonary disease. This was evident for 1 of 6 residents (Resident #20) reviewed for respiratory care; 2a) ensure respiratory care was provided consistent with professional standards of practice as evidenced by: 2b) ensure orders for the use of a BiPAP machine for a resident with a known history of obstructive sleep apnea were continued when the resident was re-admitted after a brief hospitalization; and failed to develop a care plan to address the sleep apnea and BiPAP usage; 2c) develop a care plan addressing sleep apnea and the use of CPAP machine for two months and once developed the care plan failed to address specific issues resident was experiencing with the CPAP usage. This was found to be evident for 2 out of 6 residents (Resident #12 and #117) reviewed for respiratory care; 3a) provide respiratory care for residents (Resident #17); 3b) label oxygen tubing when initiated and ensure a resident's respiratory care equipment was clean and maintained (Resident #32). This was evident for 2 of 6 residents (Resident #17 and #32) reviewed during the annual survey.
The findings include:
1) Observation was made of Resident #20 on 11/15/19 at 9:02 AM. Resident #20 was lying in bed; the head of the bed was noted to be approximately at a 45-degree angle. The resident was wearing a nasal cannula (a lightweight tube that is hooked onto an oxygen concentrator that delivers oxygen to a resident who needs respiratory help). The nasal cannula was hooked onto the oxygen concentrator and was delivering 3.0 liters (L) of oxygen. Resident #20 was observed again with a second surveyor at 2:27 PM on 11/15/19 and was receiving oxygen at the same rate of 3.0 L.
On 11/15/19 at 2:45 PM, a review of Resident #20's TAR (treatment administration record) revealed an order for oxygen at 2 L/min continuous and was documented as done at that time. The order on the TAR was originally prescribed on 1/18/19.
At 3:19 pm the Director of Nursing (DON) was asked to make a copy of Resident #20's November 2019 TAR. Upon receipt of the copied TAR the DON was advised of the incorrect oxygen flow and failure of the staff to accurately document oxygen administration.
Review of Resident #20's written care plans on 11/20/19 revealed a plan of care with a focus area for Resident exhibits or is at risk for respiratory complications related to COPD (Chronic Obstructive Pulmonary Disease). There was only one intervention written; O2 as ordered via nasal cannula. The facility had failed to follow/implement the plan of care for Resident #20.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on medical record review, observation and interview it was determined that the facility failed to ensure sufficient staffing as evidenced by failure to administer medications in a timely manner ...
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Based on medical record review, observation and interview it was determined that the facility failed to ensure sufficient staffing as evidenced by failure to administer medications in a timely manner due to a delay in obtaining electronic health record access for an agency nurse. This was found to be evident for 1 out of the 2 nurse ' s observed for medication administration.
The findings include:
On 11/19/19 at 8:19 AM Nurse #66 reported she works for an agency and that she will be administering medications once she is able to get access to the [electronic health record (EHR)] system. At 8:20 AM Resident #47 was observed in the hallway requesting pain medication from Nurse #66.
The unit nurse manager #5 confirmed this was nurse #66's first day at the facility. Review of the posted staffing revealed Nurse #66 was assigned to care for Resident #47. At 8:26 AM Nurse #66 was observed on the phone. At 8:40 Nurse #66 remained on the phone, she confirmed she still did not have access to the EHR. The nurse went on to report that she arrived at 7:00 AM, at 7:45 AM she was informed that she would have EHR access in 15 minutes. At 8:58 AM Nurse #66 was unable to gain access to the EHR. At 9:00 AM Resident #47 reports he would be going downstairs but would be back. At 9:04 AM Nurse #66 was again observed on the phone attempting to get EHR access.
On 11/19/19 at 9:11 AM Nurse #66 reported she now had EHR access and began preparing medications for Resident #11.
During the observation of Resident #11's medication administration, at 9:19 AM Resident #117 approaches Nurse #66 requesting his/her medications. Resident #117 informed the nurse that breakfast was already here and the medication is suppose to be taken before eating. The nurse acknowledged the resident's request and the resident returned to his/her room. At 9:29 AM Resident #47 had returned to the unit and was waiting by the medication cart requesting pain medication.
Prior to preparing and administering Resident #47's pain medication the unit nurse manager moved the resident to the shower room. Nursing staff obtained the resident's blood pressure prior to preparing the resident's morning medications. At 9:37 AM Nurse #66 was observed preparing the resident's medications, the resident had reported the pain level to be a level 9. The nurse was observed administering the 3 other medications along with the pain medication.
Review of the Medication Administration Record revealed the pain medication, which had been requested as early as 8:20 AM was administered at 9:45 AM.
On 11/19/19 at 9:50 AM the Director of Nursing (DON) reported that she is responsible for ensuring newly arrived agency staff have access to the EHR. She went on to report that she had been on the unit earlier and denied that she had been informed that the nurse did not have access, stating she can obtain access in 15 minutes. Surveyor then reviewed the observation, with the DON and the Administrator, of the nurse not having access to the EHR for an hour and the delay in the administration of pain medication which was reported at a level 9 by the time the medication was administered.
On 11/19/19 at 10:34 AM surveyor observe Nurse #66 preparing Resident #117's medication. The nurse confirmed she is preparing the medications that had been due at 8:00 AM. The nurse prepared 10 pills total. Prior to taking the pills the resident poured them out and counted the 10 pills out. The resident expressed concern regarding the sulcralfate which had been due prior to breakfast. The nurse informed the resident that this was the dose that was due at 11 AM, prior to lunch.
After the medication pass observation surveyor reviewed the orders and the Medication Administration Record. An order was found for Sucralfate to be given before meals and at bedtime for ulcers.
On 11/19/19 at 11:07 AM review of the medical record revealed an order for Tadalafil 20 mg give 2 tablet by mouth one time a day for pulmonary hypertension. Tadalafil was not one of the medications observed as having been administered. Review of the MAR revealed the nurse had documented that the 9:00 AM dose of Tadalafil had been administered.
On 11/19/19 at 11:14 AM Nurse #66 confirmed the Tadalafil had not been administered. She reports that she wrote the medication down because it was not available but also confirmed that she had documented that it had been administered and stated she needed to go check if it was available. The unit nurse manager #5 was called over by the nurse at this time. The unit nurse manager identified a medication card with a medication named Alyq 20 mg as the Tadalafil. The Nurse #66 checked to make sure these were the same medications, stating this is not the name of the medication in the [electronic health record]. The nurse then prepared and administered the two 20 mg tablets.
On 11/21/19 at 3:02 PM surveyor reviewed the three observed errors with the unit nurse manager #5: the missed medication that was due prior to breakfast; the medication that was not administered but staff had documented that it was administered, and the pain medication that was delayed in being administered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on review of employee files and staff interview it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) are evaluated annually...
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Based on review of employee files and staff interview it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) are evaluated annually and provided appropriate re-education based on the outcome of these evaluations. This was found to be true for 4 of 4 GNA employees (GNA #27, #28, #29, #30) reviewed for annual evaluations. This deficient practice has the potential to affect all the residents in the facility.
Findings include:
On 11/21/19 at 2:15 PM a review of employee files revealed that annual evaluations for GNA's with over one year of service had not been completed.
Review of GNA #30's file revealed no annual evaluation since 2016. Review of GNA #28 and #29's file revealed they had not had an annual evaluation since 2017. Review of GNA #27's showed no evidence of an annual evaluation.
On 11/21/19 at 10:26 AM in an interview with the Director of Nursing she was made aware of the concern regarding the process of annual evaluations for GNA's, and stated that they are completed the month of their anniversary date but some slip through the cracks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During an interview with Resident #99 on 11/15/19 at 10:29 AM, the resident reported that he/she had not had their Triumeq me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During an interview with Resident #99 on 11/15/19 at 10:29 AM, the resident reported that he/she had not had their Triumeq medication since being admitted to the facility on [DATE] until yesterday (11/14/19). The resident reported speaking with various nurses and a supervisor regarding this issue and was told his/her insurance would not cover the medication. He/she stated I told them to call my doctor at [acute care facility] to get the medication.
A medical record review on 11/15/19 at 11:00 AM, revealed an admission history and physical completed by Certified Registered Nurse Practitioner (CRNP) #21 on 10/23/19, which documented that Resident #99 was admitted due to a right knee prosthetic joint infection to continue Intravenous (IV) (directly in the vein) antibiotics and rehabilitation. She noted in this document that the resident was receiving Triumeq to treat HIV. In addition, review of the Physician Order Summary for October 2019, revealed the resident had an order for Triumeq dated 10/22/19 which was discontinued and reordered on 11/14/19.
In addition, review of the Medication Administration Record (MAR) for October 2019, revealed that the medication was not administered until 10/26/19. Review of the MAR for November 2019, revealed the medication was administered some days and then not on other days.
On 11/20/19 at 11:17 AM, review of the facility's pharmacy receipt log for 10/2019 and 11/2019, revealed that the Triumeq was not dispensed to the facility until 11/13/19. In addition, review of facility's medication list available in the drug storage box revealed that the Triumeq was not kept on hand in the facility. This confirmed that Resident #99 went 23 days without his/her Triumeq medication.
During an interview with the Director of Nursing (DON) on 11/20/19 at 12:43 PM, she confirmed the medication was not sent from another pharmacy.
An interview with RN #39 on 11/20/19 at 1:28 PM, revealed that she had called the pharmacy on 10/24/19 and was informed the Triumeq was going to cost $3,000.00 because insurance was not going to cover it. She reported that she handed the information on sticky note to the Assistant Director of Nursing (ADON) #15, whom was the acting Unit Manager, that day. She reported calling the pharmacy a second time on 11/10/19, and was informed that they had faxed a form to the facility. She stated she was aware that the house supervisor gave it to the Director of Nursing (DON) to complete.
An interview on 11/20/19 at 2:04 PM, with ADON #15, revealed that the pharmacy was expected to send a form to obtain permission to bill the facility for medications that were not covered by insurance. However, the form was not consistently received for each non-covered medication. At times the nurse would report the medication missing during a medication pass and at that time the pharmacy was contacted and would inform the facility it was non-covered, so there was no set process of how the facility finds out about a non-covered medication. Once the form was received it must go to the DON for approval or denial of payment. The ADON was not aware that she could sign the form. She reported that she was aware of the non-covered medication for Resident #99 and remembered RN #39 making her aware that the medication was going to cost $3,000 and she told RN #39 to call the pharmacy for the form and give it to the DON. Also, the ADON informed the DON during the stand-up meeting on the same day. However, she was unable to provide any documentation that she had addressed the issue, and when she heard nothing more about the missing medication she did not follow-up to ensure that the resident had all of his/her prescribed medications even though she was the acting Unit Manager on the unit the resident resides.
A subsequent interview with the DON on 11/20/19 at 2:29 PM, regarding the process for obtaining a non-covered medication from the pharmacy. She stated that the nurse should call the pharmacy and when the pharmacy sends the form the nurse was to give it to the Unit Manager or the DON for approval. She stated that usually the pharmacy would send a 7 day supply. She denied she was told on 10/24/19, by the ADON, about the issue with Resident #99's Triumeq and stated the first time she heard about it was on 11/10/19 from the resident. However, she did not conduct an investigation to determine the cause of the breakdown which allowed a resident to go 23 days without a prescribed medication. In addition, she was not sure why the ADON was not aware that she could have completed the form from the pharmacy and approved the medication.
During an interview with the Pharmacy Compliance Technician on 11/20/19 at 3:34 PM, she reported that they sent the [NAME] to the Facility Form to the facility and they use the fax for the specified floor that the resident resides. She stated that because this medication was going to cost $3,000.00 she would expect the DON to review and sign the form and once the form is sent there is no follow-up from the pharmacy, we have too many clients. On 11/11/19, the pharmacy received a phone call from the facility asking about the medication and received a completed [NAME] to the Facility Form that day.
The DON, Administrator #2, and Administrator #3 were informed of the concerns on 11/21/19 at 11:36 AM. (Cross Reference: F580, F658, F684, F760, and F842)
Based on review of controlled drug Shift Count sheets, family interview, medical record review and staff interview it was determined the facility failed to: 1) provide medications in a timely manner. This was evident for 3 of 15 complaints (Resident #136, #135, #137) that were investigated; 2) ensure an account of all controlled drugs was completed by two nursing staff at the change of shift. This was found to be evident on 2 of the the 3 nursing units in the facility; 3) have a process in place to ensure that ordered non-covered medications were obtained from the pharmacy in a timely manner for administration. This was evident for 1 of 8 residents (Resident #99) reviewed for pharmacy reviews.
The findings include:
1a) An interview was conducted with the family member of Resident #136 on 11/21/19 at 9:36 AM who stated that Resident #136 did not receive the medication Suboxone for 2 days and when you need it you need it.
Review of the medical record for Resident #136 on 11/21/19 revealed the resident was admitted to the facility on [DATE] from an acute care facility. Review of the 8/23/19 hospital discharge summary revealed a list of medications that the resident was prescribed to take while at the facility which included the medication buprenorphine-naloxone (Suboxone) 4 mg - 1 mg sublingual film which was to be taken 2 times per day for narcotic dependence.
Review of Resident #136's August 2019 Medication Administration Record (MAR) revealed nurse's initials with notations that the medication was not given on 8/24/19 at 9 AM, 8/24/19 at 9 PM and 8/25/19 at 9 AM.
Review of the pharmacy controlled substance Prescription (Class II-V) form documented Suboxone was to be given BID (twice per day) and was faxed to the pharmacy on 8/24/19 at 15:22 (3:22 PM). The resident was admitted on [DATE] and the orders were verified with the physician on 8/23/19 at 20:56 (8:56 PM).
A nursing note dated 8/24/19 at 22:40 (10:40 PM) documented, Pharmacy called at 6 pm, they said it would be sent out stat. Still not here at 10 pm. Pharmacy called again. The pharmacist said he would send it stat again. To be given by night nurse when it arrives.
A nursing note dated 8/24/19 at 23:41 (11:41 PM) documented, Patient somewhat upset that suboxone has not been delivered by pharmacy yet. Pharmacy called and will send stat.
A physician's history and physical was done on 8/25/19 at 11:00 AM and documented that the resident feels some withdrawal symptoms now. The resident did not receive the first dose of medication until 8/25/19 at 6 PM.
1b) An interview was conducted with the family member of Resident #135 on 12/4/19 at 8:38 AM. The family member stated that the facility was aware that Resident #135 was going to be admitted on [DATE] and the facility did not have the IV (intravenous) antibiotics. Review of the acute care hospital Discharge summary dated [DATE] documented the resident was to take Oxacillin 2 grams IV every 4 hours for 22 days due to an infection.
Review of Resident #135's February 2019 MAR documented that the resident did not receive the Oxacillin until 1300 (1 PM) on 2/2/19. The resident missed the 5 AM and 9 AM doses. RN #64 was the nurse on duty at the time.
Review of the Individual Performance Improvement Plan for RN #64, that was given to the surveyor by the Director of Nursing, documented that on 2/2/19 the RN was assigned to Resident #135 who was admitted on [DATE] and was advised in report that the resident's medications had not arrived. The document stated that RN #64 failed to call the pharmacy to follow-up and that RN #64 did not pull the medications that were available from the Omnicell (interim box). Policy is that if medications are not available you are to pull from the Omnicell and if not in the Omnicell, you are to call the pharmacy to have sent STAT. Failure to do so is a delay in treatment.
1c) Review of Resident #137's medical record on 12/4/19 documented that the resident was admitted to the facility from an acute care facility on 1/15/19 with an order for medications which included; Clopidogrel Bisulfate 75 mg for blood clot prevention, Entresto 24-26 mg 1 tablet twice a day which was used for heart failure, Flomax 0.4 mg for benign prostatic hyperplasia and Levothyroxine 50 mcg for hypothyroidism. Review of Resident #137's January 2019 MAR documented that on 1/16/19 those medications were not available.
On 12/4/19 at 12:20 PM the surveyor requested the inventory list of medications available from the Omnicell. Clopidogrel 75mg, Flomax 0.4 mg and Levothyroxine 25 mcg were available.
An interview was conducted with the Director of Nursing on 12/4/19 at 1:00 PM who confirmed the findings.
2) On 11/18/19 at approximately 10:50 AM review of the Shift Count sheets for the second floor medication cart one and cart two failed to reveal documentation that the nurse coming on duty on 11/18/19 at 7:00 AM completed the shift count.
Per regulations facility's shall maintain a signed record of a schedule 2 count at each change of shift. Schedule 2 medications have a high potential for abuse and include narcotics such as oxycodone.
On 11/18/19 at 10:53 AM Nurse #13 reported that the nurse is suppose to sign the shift count sheet when the count is completed. Nurse #13 confirmed that the Shift Count sheet was not signed that morning for the book associated with his medication cart.
On 11/18/19 at approximately 11:00 AM review of the Shift Count sheets for the fourth floor medication cart #3 failed to reveal documentation that the nurse coming on duty on 11/18/19 at 7:00 AM completed the shift count.
On 11/18/19 at 11:28 AM Nurse #40 reported he took over the medication cart from the supervisor and confirmed that he did not complete a count when he took over the cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A review of Resident #99's medical record on 11/15/19 at 11:00 AM, revealed an admission history and physical completed by Ce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A review of Resident #99's medical record on 11/15/19 at 11:00 AM, revealed an admission history and physical completed by Certified Registered Nurse Practitioner (CRNP) #21 on 10/23/19, documented that Resident #99 was admitted on [DATE]. In addition, it revealed an October 2019 and November 2019 Physician Order Summaries documenting an order for Triumeq 600-50-300 mg daily dated 10/22/19. Review of progress notes dated 10/22/19 - 11/15/19, revealed a Pharmacist Medication Regimen Review dated 11/5/19 that documented, A medication regimen review was performed with no irregularities.
On 11/20/19 at 11:17 AM, review of the facility's pharmacy receipt log for 10/2019 and 11/2019, revealed that the Triumeq was not dispensed to the facility until 11/13/19.
A subsequent interview with the DON on 11/20/19 at 2:29 PM, revealed the pharmacy usually sends a 7 day supply of a medication that is not covered by insurance.
The DON, Administrator Staff #2, and Administrator, Staff#3 were informed of the surveyor's concerns on 11/21/19 at 11:36 AM.
Cross Reference F580, F658, F684, F760, and F842
1e) On 11/25/19 at 11:05 AM, review of Resident #32's medical record revealed a physician's order for Methadone (medication to treat addiction) that failed to clearly identify the dose of the medication that the resident was to receive.
Review of Resident #32's November 2019 MAR (medication administration record) revealed a 10/24/18 order for Methadose (Methadone) tablet soluble 40 mg (milligrams). Give 1.75 tablet by mouth one time a day for substance abuse. Give 1.75 tablets to equal 60 mg, dissolve in water. Please go by the date that is on the bottle from clinic. The order to give 1.75 (1-3/4 tablets of 40 mg strength tablets to equal 60 mg was inaccurate as 1.75 tablets of 40 mg strength tablets equals 70 mg. 1.5 tablets of 40 mg would equal 60 mg). The methadone order failed to clearly identify whether Resident #32 was to receive 60 mg or 70 mg of methadone.
Review of pharmacist monthly drug regimen reviews for Resident #32 revealed pharmacy drug regimen reviews conducted on 1/2/19, 2/5/19, 3/5/19, 4/2/19, 5/1/19, 6/3/19, 7/9/19, 8/1/19, 9/3/19 10/3/19, and 11/4/19 failed to identify the irregularity related to the resident's methadone order which failed to have a clear indication as to whether the resident Methadone dose was 60 mg or 70 mg.
On 11/26/19 at 1:12 PM, during an interview, the Director of Nurses was made aware of the above findings and indicated that he/she would have expected the pharmacist would have identified the dose discrepancy in the resident's methadone order.
Cross Reference F 760
1c) Resident #71's medical record was reviewed on 11/25/19 at 10:03 AM. The resident's physician orders included but were not limited to:
-Milk of Magnesia (MOM) Suspension give 30 ml (milliliters) by mouth as needed for Constipation give at bedtime if no BM (bowel movement) in 3 days.
-Dulcolax Suppository 10 mg rectally as needed for constipation, if no results give Miralax by next shift.
-Fleet Enema insert 1 dose rectally as needed for constipation if no result from Dulcolax within 2 hours. If no results from Fleet enema call MD/APP (physician/advanced practice provider) for further orders.
The physicians orders were not clear as to when the Dulcolax suppository should be given to the resident. The resident did not have a physician's order for the Miralax referred to in the Dulcolax suppository order.
1d) Resident #4's medical record was reviewed on 12/3/19 at 2:19 PM. Resident #4' physician orders included but were not limited to:
-Oxycodone HCl 10 mg (milligrams) give 3 tablets by mouth every 8 hours PRN (as needed) for moderate - severe pain and Acetaminophen tablet 325 mg give 2 tablets by mouth every 4 hours PRN for Mild Pain. The orders did not indicate how staff determined if the resident's pain was mild, moderate or severe.
-Milk of Magnesia (MOM) suspension give 30 ml by mouth PRN (as needed) for constipation give at bedtime if no BM (bowel movement) in 3 days.
-Dulcolax suppository 10 mg PRN for constipation if no result from MOM by next shift.
-Fleet enema PRN for constipation if no result from Dulcolax within 2 hours, if no results from the enema call the physician/practitioner for further orders.
-Colace Capsule (stool softener) 100 mg give 1 capsule by mouth every 12 hours PRN for bowel regimen. The order did not indicate when the Colace should be administered to the resident.
Review of the consulting pharmacist monthly drug regimen review failed to reveal that the pharmacist identified and referred these irregularities to the physician.
Resident #4's physicians orders included Trazodone HCl (a psychotropic medication used to treat depression) 100 mg (milligrams) give 1 tablet PO (by mouth) every 24 hours PRN. The order was written on 10/2/19 with the indication: depression. On 10/7/19, the physician's order was rewritten, and the indication was changed to insomnia at HS (hour of sleep). The PRN Trazodone order was not limited to 14 days. Further review of the record revealed that Resident #4 did not have a diagnosis of nor plan of care for insomnia.
Review of the monthly consultant pharmacist review log revealed that a recommendation was made to the physician on 10/4/19 however it was not in the resident's record. On 12/5/19 at 10:52 AM the Director of Nursing (DON) confirmed it was not in the record, that she was unable to find the recommendation with the physician's response but provided the surveyor with a copy of the initial consultation report.
Review of the recommendation revealed that the consultant pharmacist requested the physician: Please discontinue PRN Trazodone or if it cannot be discontinued document the diagnosed specific condition, intended duration of therapy and rationale for the extended time period prior to issuing a new order. It also included the regulation for limiting PRN psychotropic medications to 14 days.
The Director of Nursing was made aware and confirmed these concerns on 12/6/19 at 11:07 AM.
Cross reference:F757, F758, F842
1b) Review of the medical record for Resident #123 on 12/3/19 revealed a physician's order for Acetaminophen 325 mg every 4 hours as needed (PRN) for mild pain and Tramadol 50 mg every 6 hours as needed for pain. There was no indication of when to give the Tramadol and the Tylenol order had mild pain but did not have a numerical indication.
A pharmacy review was conducted on 3/9/19 and stated, no irregularities noted.
On 12/3/19 at 1:25 PM RN #39 was asked when she would give PRN Tylenol versus PRN Tramadol. RN #39 stated, well Tylenol you give every 6 hours and Tramadol every 4 hours. The surveyor again said, which one would you give if the resident was complaining of pain. RN #39 said, I guess it depends on what they ask for. If the pain level is like a 6, I would give Tramadol and if a 3, Tylenol.
On 12/3/19 at 1:30 PM RN #5 was asked the same question and the response was, I would give Tramadol if moderate to severe pain. When asked what that would be, she said 1-5 for moderate, something like that. I am not really sure how the doctor wrote the order.
Review of Resident #123's March 2019 Medication Administration Record (MAR) documented the Tramadol was given for pain levels ranging from 2 to 9. Acetaminophen was not documented as offered or administered.
On 12/2/19 at 2:02 PM an interview was conducted with the Director of Nursing (DON) who stated that they were working on the parameters. The surveyor informed the DON of the pharmacy review.
Based on medical record review and staff interview it was determined the facility staff failed to: 1) ensure that irregularities were identified during monthly drug regimen reviews, referred and addressed by the physicain. This was evident for 4 of 7 residents (Resident #104, #123, #71, and #4) reviewed for unnecessary medications and 1 of 6 residents (Resident #32) reviewed for respiratory; and 2) alert the attending physician when a medication currently ordered for a new admission had not been sent to the facility. This was evident for 1 of 8 residents (Resident #99) reviewed for pharmacy reviews.
The findings include:
1a) Resident #104's medical record was reviewed on 11/21/19. Review of the electronic record revealed that the consulting pharmacist had made recommendations related to the resident's medication regimen on 1/2/19. The consultation reports for 1/2/19 were not found the residents medical record. The unit manager was notified of the missing documents and had obtained the missing documents electronically from the pharmacy. Review of the pharmacy consultation reports of 1/2/19 recommended reduction of the medication Namenda based on manufactures recommendations that the prescribed dosage could have an adverse effect to the resident. The second recommendation was for the discontinuation of Fleet enema related to potential adverse effects to the resident. Both forms/documents were not acted upon by the resident's attending physician. The pharmacist re-issued the recommendations of 1/2/19 on 3/6/19. Continued record review revealed that both recommendations were acted upon on 3/8/19 (2 months after initial recommendation). The Fleets enema was discontinued, and the medication Namenda was changed to a lower dose as recommended by the pharmacist.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
3) On 12/2/19 at 10:55 AM, Resident #10's medical record was reviewed. Review of Resident #10's November 2019 MAR (medication administration record) revealed a 6/27/19 physician order for Acetaminophe...
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3) On 12/2/19 at 10:55 AM, Resident #10's medical record was reviewed. Review of Resident #10's November 2019 MAR (medication administration record) revealed a 6/27/19 physician order for Acetaminophen (Tylenol) (pain medication) every 6 hours by mouth as needed for general discomfort and a 6/26/19 order for Oxycodone (narcotic pain medication) every 12 hours as needed for pain. There was no clear indication in the orders as to when to give which medication, the Acetaminophen versus the Oxycodone for pain.
The Director of Nurses was made aware of these findings on 12/3/19 at 9:40 AM.
2) Resident #4's record was reviewed on 12/3/19 at 2:19 PM. The Physicians orders included but were not limited to: 1) Oxycodone HCl 10 mg (milligrams) give 3 tablets by mouth every 8 hours PRN (as needed) for moderate - severe pain. 2) Acetaminophen tablet 325 mg give 2 tablets by mouth every 4 hours PRN for Mild Pain.
The orders did not define the parameters to be used by staff to determine if the residents pain was mild, moderate or severe. Review of the Medication Administration Record (MAR) revealed that Resident #4 received Oxycodone Hcl 28 times during November 2019. The MAR did not reflect the resident's level of pain each time the medication was administered.
The Director of Nursing was made aware of these concerns on 12/6/19 at 11:07 AM.
Cross reference F 756
Based on review of the medical record and staff interview it was determined that the facility staff failed to ensure that medications had adequate parameters to indicate when to administer the medications. This was evident for 2 (Resident #123 and #4) of 7 residents reviewed for unnecessary medications and 1 of 8 residents (Resident #10) reviewed for hospitalization.
The findings include:
1) Review of the medical record for Resident #123 on 12/3/19 revealed a physician's order for Acetaminophen 325 mg every 4 hours as needed (PRN) for mild pain and Tramadol 50 mg every 6 hours as needed for pain. Review of the March 2019 Medication Administration Record (MAR) documented that Resident #123 received Tramadol on 3/10/19 and 3/18/19 for a pain level of 7, on 3/14/19 for a pain level of 9, on 3/15/19 and 3/20/19 for a pain level of 5, on 3/19/19 for a pain level of 4 and on 3/16/19 for a pain level of 2. Acetaminophen was not signed off as given in March 2019.
On 12/3/19 at 1:25 PM RN #39 was asked when she would give PRN Tylenol versus PRN Tramadol. RN #39 stated, well Tylenol you give every 6 hours and Tramadol every 4 hours. The surveyor again said, which one would you give if the resident was complaining of pain. RN #39 said, I guess it depends on what they ask for. If the pain level is like a 6, I would give Tramadol and if a 3, Tylenol.
On 12/3/19 at 1:30 PM RN #5 was asked the same question and the response was, I would give Tramadol if moderate to severe pain. When asked what that would be, she said 1-5 for moderate, something like that. I am not really sure how the doctor wrote the order.
There was no indication of when to give the Tramadol and the Tylenol order had mild pain but did not have a numerical indication. As documented above, the Tramadol was given for pain levels of 2 and 4 and neither RN could give a definitive answer as when to give which PRN pain medication.
On 12/2/19 at 2:02 PM an interview was conducted with the Director of Nursing (DON). The surveyor informed the DON about the parameters and she stated, we are working on that now, putting the parameters in.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 12/2/19 at 10:55 AM, Resident #10's medical record was reviewed. Review of Resident #10's November 2019 MAR (medication ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 12/2/19 at 10:55 AM, Resident #10's medical record was reviewed. Review of Resident #10's November 2019 MAR (medication administration record) revealed a 6/26/19 physician order for Ativan (Lorazepam) (anxiolytic) Solution intramuscularly every 6 hours as needed for seizures. The order had no discontinuation/end date, was not limited to 14 days duration and had no documented rationale for continuing the order beyond 14 days.
The Director of Nurses was made aware of these findings on 12/3/19 at 9:40 AM.
Based on medical record review and staff interviews, it was determined the facility staff failed to ensure that psychotropic medication prescribed as needed included the frequency the medication could be administered and was limited to 14 days or when a rationale for an extended time period documented in the medical record had a specific duration. This was evident for 1 of 7 residents (Resident #4) reviewed for unnecessary medications and 1 of 8 residents (Resident #10) reviewed for hospitalization.
The findings include:
1) Resident #4's medical record was reviewed on 12/3/19 at 2:19 PM. The Physicians orders included but were not limited to Trazodone HCl (a psychotropic medication used to treat depression) 100 mg (milligrams) give 1 tablet PO (by mouth) every 24 hours PRN. The order was written on 10/2/19 with the indication of depression.
On 10/7/19, the physicians order was rewritten, and the indication was changed to insomnia at HS (hour of sleep). The PRN Trazodone order was not limited to 14 days.
The resident's Medication Administration Record (MAR) revealed that he/she did not receive the PRN Trazodone for insomnia since readmission to the facility on [DATE]. Further review of the record revealed that Resident #4 did not have a diagnosis of nor plan of care for insomnia.
On 10/4/19 the consulting pharmacist recommended that the physician discontinue the PRN Trazodone order or document the diagnosed specific condition for use and to limit the PRN use to 14 days. The recommendation was not addressed by the physician.
The Director of Nursing was made aware and confirmed these concerns on 12/6/19 at 11:07 AM.
Cross reference F 756
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews it was determined that the facility failed to ensure resident's were free fr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews it was determined that the facility failed to ensure resident's were free from significant medication errors as evidenced by: 1a) failing to administer medications as ordered (Resident #99); 1b) the administration of an incorrect antibiotic via intravenous (IV) route (Resident #99); and 2) failing to administer the correct dose of medication (Resident #32). This was found to be evident for 2 out of 104 residents (Resident #99 and #32) reviewed during the annual survey.
The findings include:
1a) During an interview with Resident #99 on 11/15/19 at 10:29 AM, the resident reported that he/she had not had their Triumeq since being admitted to the facility on [DATE] until yesterday (11/14/19). The resident reported speaking with various nurses and a supervisor regarding this issue and was told his/her insurance would not cover the medication. He/she stated I told them to call my doctor at [acute care facility] to get the medication.
A medical record review on 11/15/19 at 11:00 AM, revealed Physician Order Summaries for October 2019 and November 2019, which documented Resident #99 had a current order for Triumeq dated 10/22/19.
Review of the Medication Administration Record (MAR) for October 2019, revealed that the medication was not available 10/23/19 - 10/26/19, then 10/26/19 -10/31/19, it was documented as being administered to the resident.
In addition, review of the MAR for November 2019, revealed that the medication was signed off as not being available on 11/1/19, 11/4/19, 11/6/19, and 11/10/19 - 11/12/19, then on 11/2/19, 11/3/19, 11/5/19, and 11/7/19 - 11/9/19 it was documented as being administered to the resident.
On 11/20/19 at 11:17 AM, review of the facility's pharmacy receipt log for 10/2019 and 11/2019, revealed that the Triumeq was not dispensed to the facility until 11/13/19. In addition, review of facility's medication list available in the drug storage box revealed that the Triumeq was not kept on hand at the facility. This confirmed that Resident #99 went 23 days without his/her Triumeq and facility staff signed the medication as being given 50% of those days.
During an interview with Nurse Practice Educator (NPE) RN #4 on 11/21/19 at 11:26 AM, he revealed that the process for documenting, eMAR (electronic medication administration record) that a medication was not available for administration was to use the key NN (Nurses' Note) and document a note either in eMAR or progress note. When he was asked about the Triumeq being marked as administrated to Resident #99 on 10/28/19, in the eMAR he reported he must have taken all the morning medications to the resident and when he came back to the medication cart he accidentally marked all of them as being administered by mistake.
An interview with LPN #6 on 11/21/19 at 2:33 PM, regarding the process staff used when a medication was not available, revealed she would document NN (nurse note) on the eMAR and then write a note that it was not available. When asked about signing the Triumeq as being given to Resident #99 on 10/27/19 and 10/31/19, she stated she must have taken all the morning medications to the resident and when she came out to the medication cart she documented them all as being administered by mistake.
An interview with the Corporate Director of Nursing (DON) #47 on 11/21/19 at 3:35 PM, revealed there is a process for marking medications as being administered or not administered in the eMAR which included to mark each medication with a Y to show that they had prepared the medication and once given to the resident then staff can go back through and press save once administered or end if the resident did not get the medication. He confirmed that it was expected that staff only click the Y once they have confirmed the medication was available for administration.
On 11/21/19 at 11:36 AM, a meeting was conducted with the Administrator Staff #2 and Administrator, Staff #3, the DON, and Corporate Nurse to inform them of the concerns.
Cross reference F658.
2) On 11/25/19 at 11:05 AM, review of Resident #32's medical record revealed a 10/24/18 physician's order for Methadone (medication to treat addiction) that failed to clearly identify the dose of medication that the resident was to receive. Review of Resident #32's November 2019 MAR (medication administration record) revealed an order for Methadose (Methadone) tablet soluble 40 mg (milligrams). Give 1.75 tablet by mouth one time a day for substance abuse. Give 1.75 tablets to equal 60 mg, dissolve in water. Please go by the date that is on the bottle from clinic. The order to give 1.75 (1-3/4 tablets of 40 mg strength tablets to equal 60 mg was inaccurate as 1.75 tablets of 40 mg strength tablets equal 70 mg. 1.5 tablets of 40 mg tablets would equal 60 mg). The Methadone order was documented as being administered to the resident every day.
On 11/26/19 at 12:00 PM, to clarify the dose of Methadone that Resident #32 was receiving, RN #13, was asked to review Resident #32's methadone order and then asked how much methadone he/she would administer to the resident. RN #13 responded that he/she would give the resident 40 mg of methadone. The surveyor then requested to see the the resident's methadone medication. From a locked narcotic box, the RN #13 removed a clear plastic bag that contained multiple green plastic bottles and stated that each bottle contained the resident's daily methadone dose. Each bottle was labeled with Resident #32's name and labeled Methadone 40 mg diskettes: 1.25 (50 mg), indicating each bottle contained only one dose of medication which was confirmed by RN #13. Following review of the medication bottles, when again asked how much Methadone was to be administered to Resident #32, RN #13 stated 40 mg. Upon further questioning, RN #13 confirmed that the resident would receive the Methadone dose that was in the green bottle. When asked again, RN #13 was unable to accurately tell the surveyor what dose of Methadone the nurse was to administer to Resident #32. On 11/26/19 at 12:20 PM, the Director of Nurses (DON) was made aware of the above findings.
On 11/26/19 at 1:12 PM, the DON confirmed the inaccuracy of the resident's methadone order and stated that Resident #32 was to receive Methadone 50 mg by mouth every day. At that time, the DON provided the surveyor with a physician's order dated 11/26/19 at 12:31 for Methadone 40 mg, give 1.25 tablet by mouth one time a day. During an interview, when asked to describe the facility's process for obtaining methadone, the DON stated that when methadone was prescribed for a resident, a Methadone Clinic provided the medication. The DON stated that the methadone was delivered with a manifest, that included the resident's name, medication, dosage and number of doses being sent, which the facility staff would sign to acknowledge the receipt of the medication. The DON stated that he/she called the Methadone Clinic and was told that Resident #32's methadone dose was changed from 60 mg to 50 mg on 11/20/19. The DON stated that the methadone clinic said that when the methadone was delivered on 10/22/19, they spoke with the Resident #32 and with the Nurse Practitioner, Staff #21 at that time and made them aware that the resident's methadone dose was going be changed on 11/20/19 to 50 mg. When asked what was delivered on 10/22/19, the DON stated 22 doses of Methadone 60 mg. At that time, when asked to provide the surveyor copies of the methadone delivery manifest documentation for Resident #32, the DON was unable to provide the surveyor with any documentation.
On 11/27/19 at 1:25 PM, the DON provided the surveyor with a fax transmittal, dated 11/26/19 from the Center for Addiction Medicine, to the DON, that stated their CRNP (certified registered nurse practitioner) spoke with the facility's NP, Staff #21 in October 2019 about the decrease in Resident #32's methadone dose and Staff #21 was in agreeance. The fax included a letter from the Center for Addiction Medicine that verified the amount of methadone, along with the dosage, and the dates that methadone medication was delivered to the facility for Resident #32 since 3/20/18. The letter indicated that Resident #32 received deliveries of Methadone 60 mg since 6/15/18 until 11/19/18, when Methadone 50 mg was delivered to the facility. A Methadone Delivery Form, signed as received on 11/19/19, was also reviewed. The form identified the medication was for Resident #32, the delivery included 35 tablets of Methadone 40 mg which was a total of 28 doses for 11/20/19 through 12/17/19 and the instructions to administer 1.25 tablets for a total dose of 50 mg per day. The form had 3 signatures, the preparer, the person who received the medication and the signature of the person who witnessed/delivered the medication.
Review of Resident #32's methadone narcotic count sheet (the number written on the sheet must match the number of doses of narcotic medication left), revealed Methadone 60 mg and the directions as directed were handwritten on the top of the form. The form documented that, on 11/4/19, the resident had 15 doses of Methadone. On 11/18/19, the form indicated that there was 1 methadone dose left. On 11/19/19, at 9:00 AM, received 28 was written on the form, and the count (amount of methadone doses) was changed to 29. There was no documentation on the form to indicate that the dose of the Methadone had changed to 50 mg as the 11/19/19 Methadone Delivery Form had indicated.
The facility staff failed to ensure that Resident #32 was free from a significant medication error by failing to accurately identify the dose of Methadone medication that Resident #32 was to receive, failing to obtain a physician's order when there was a change in a resident's medication dose, failing to ensure the resident's methadone narcotic count sheet included an accurate medication dose, failure of a nurse to be able identify the correct dose of medication a resident was to receive and failure of the facility staff to administer the correct medication dose as ordered.
1b) On 11/21/19 review of Resident #99's medical record revealed the resident had current orders, in effect since 10/23/19 for two different IV antibiotics for the treatment of a wound infection. The antibiotics were for Ampicillin to be administered every 4 hours and ceftriaxone to be administered two times a day.
Review of the Medication Administration Record (MAR) revealed documentation that the Ampicillin had been administered as ordered on 10/27/19 at 4:00 AM. Further review of the medical record revealed a Change in Condition note, written on 10/27/19 at 10:13 AM, that revealed the resident had been given IV Meropenam at 4:00 AM 10/27/19. The physician had been made aware and an order was received to hold the 8:00 AM ampicillin dose.
Further review of the medical record failed to reveal documentation that the resident had an order for Meropenem (also known as Merrem). Meropenem is an antibiotic.
On 11/26/19 review of the incident report related to this medication error confirmed that Meropenam dated 10/27/19 4 AM had been administered to the resident. No documentation was found that there had been any investigation by the facility regarding this medication error or interventions added after the event. On 11/26/19 at 1:20 PM the Director of Nursing reported that she would check to see if any interventions had been put in place as a result of this error. As of time of exit on 12/11/19 no additional information had been provided regarding this medication error or any interventions put in place to prevent re-occurrence.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined that the facility failed to ensure medications were kept in secured locations. This was found to be evident on 2 out of 3 units in the facility and...
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Based on observation and interview it was determined that the facility failed to ensure medications were kept in secured locations. This was found to be evident on 2 out of 3 units in the facility and had the potential to affect all residents.
The findings include:
1) On 11/15/19 at 9:20 AM surveyor observed an open bag labeled Pharmacy Return on the counter in the back of the 2nd floor nursing station. There was no door to the nursing station and the back counter was easily accessible upon entering the station. The only staff at the nursing station at this time was the ward clerk #69.
On 11/15/19 at 1:56 PM no staff are observed in the nursing station at this time. The Pharmacy Return bag was again observed unsecured on the back counter. Surveyor continued to observe the Pharmacy Return bag. At 2:05 PM Nurse #6 arrived on the unit. Observation of the medications in the bag, with nurse #6, revealed more than 15 different medications including: antibiotics, anti-seizure, antidepressant, and antipsychotic medications. Nurse #6 reported these medications were from a resident who had been discharged . She went on to report that the bag was supposed to be sealed and kept back there behind the door [indicating the medication storage room]. Nurse #6 reported that she was going to give the medications to the manager at this time, stating she was not sure if the nurse that was here today knows how to return them. Surveyor reviewed with Nurse #6 that the bag had been observed earlier on the unit as well.
2) On 11/19/19 at 9:11 AM surveyor observed Nurse #66 in Resident #11's room obtaining the resident's blood pressure. While the nurse was in the room surveyor observed a vial of medication on top of the nurse's medication cart, which was located in the hallway. The unit nurse manager #5 was informed of the observation. Unit manager #5 identified the medication as Albuterol and stated they must have left that, she then secured the medication in the medication cart.
3) On 11/20/19 at 8:30 AM Nurse #13 was observed in Resident #55's room assessing the resident's blood pressure and the nurse's back was to the medication cart at this time. Surveyor observed a container of insulin sitting on the medication cart located in the hall just outside Resident #55's room. At 8:39 AM Nurse #13 confirmed it was a vial of humalog insulin and reported he had just administered the insulin to another resident; the nurse proceeded to secure the insulin in locked medication cart.
On 11/21/19 at 2:33 PM surveyor reviewed the concern regarding the unattended insulin with the unit nurse manager #8.
On 12/5/19 approximately 5 PM, the concern regarding medication storage was reviewed with the Administrator, Staff #3 and the Director of Nursing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview and medical record review, it was determined that the facility administration...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively in order to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by 1) failing to ensure facility staff protected residents from abuse and neglect 2) failing to ensure the facility reported investigations to the Survey Agency, the Office of Health Care Quality (OHCQ) within the required time frame, 3) failing to ensure incidents of missing property, alleged verbal a physical abuse and the administration of Narcan were thoroughly investigated, 4) failing to ensure residents received medication as prescribed and the administration of medication was accurately documented, 5) failing to ensure residents' received care and treatment to prevent pressure ulcers and promote healing, including, but not limited to ensuring a resident attend wound clinic appointments, resident wounds had treatment orders, wound assessments were documented weekly, wound care supplies were available and wound consult reports were in the resident's medical record, 6) failing to ensure physicians reviewed the resident's total program of care, including an accurate assessment of a resident's wound, ensuring physician documentation was current and accurate, and residents' wounds had treatment orders that were accurately written. The administration's failure to ensure processes were in place that could identify and correct deficient practice in care had the potential to adversely affect the health and safety of all the residents in the facility.
The findings include:
1) Review of facility reported incidents reported to OHCQ (Office of Health Care Quality) revealed abuse was substantiated for 8 residents (#60, #116, #141, #142, #143, #133, #140, #63). The failure of the facility to have processes in place to prevent resident abuse contributed to a deficient practice that resulted in a harm. Cross Reference F 600
a. A facility reported incident reported to OHCQ (Office of Health Care Quality) on 12/4/19, revealed Resident #116 was observed to have his/her hand in Resident #60's pants. Resident #116 had a care plan initiated on 3/22/19 that identified the resident had a tendency to exhibit sexually inappropriate behavior related to making sexually suggestive remarks and inappropriate touching female residents. During an interview, the Director of Nurses (DON) reported that the care plan was initiated when another resident accused Resident #116 of inappropriate touching. The Administer confirmed the facility substantiated the abuse by Resident #116 against Resident #60 on 12/11/19 at 11:43 AM.
b. A facility reported incident revealed on 11/10/19 a GNA (Geriatric Nursing Assistant), Staff #32, closed Resident #116's door without the resident's consent, had a verbal altercation with the resident and pushed the resident to the floor. The facility substantiated that the abuse occurred.
c. A facility reported incident reported on 8/20/18, revealed that Resident #141 reported on 8/18/18 that GNA #61 told the resident an expletive word and gave the resident the middle finger; the resident had a fall and a verbal altercation occurred between GNA #61 and Resident #141. The verbal abuse of Resident #141 was substantiated by the facility.
d. A facility reported incident revealed that Resident #142 was verbally abused by staff when an employee used a profane term when talking to the resident which was substantiated by the facility.
e. A facility reported incident revealed Resident #143, who was transgender, reported that Staff #62 referred to the resident as him or her or whatever. The facility substantiated that emotional abuse occurred. On 12/4/19, the DON indicated that sensitivity training had been done, however could not find the sign-in sheets as to who was trained.
f. A facility reported incident revealed on 8/26/19, Staff #58, unit secretary, was verbally abusive to Resident #133. The facility substantiated the verbal abuse allegation
g. Review of a facility reported incident revealed on 8/11/19, Resident #140 reported to the to the social worker that a GNA, Staff #59, failed to provide the resident with incontinence care during the previous night. Neglect was substantiated by the facility.
h. A facility reported incident reported that on 11/22/19 Resident #63 reported that GNA #57 grabbed the resident's left arm and pushed the resident back from a sitting position back to the mattress. The abuse was substantiated by the facility.
2) Review of facility documentation and staff interviews, it was determined that the facility's administration failed to report the investigations in accordance with State law, to the State Survey Agency, the Office of Health Care Quality (OHCQ) no later than 24 hours of the events that caused the allegation and failed to report the results of all investigations within 5 working days of the incident. This was evident for 11 of 33 residents (#127, #20, #125, #42, #76, #101, #129, #144, #152, #154, #155) reviewed for abuse. Following documentation review of the facility reported incidents, interviews conducted with the Director of Nurses and/or the Administrator #3 confirmed that the facility failed to report the investigations in accordance with State law.
Cross reference F 609.
3) The facility failed to thoroughly investigate allegations of abuse that included missing property, alleged verbal and physical abuse and the administration of Narcan (Opioid antagonist used in the treatment of opioid overdose). During the survey, 33 residents were reviewed for abuse and neglect and it was found that the facility failed to ensure allegations were thoroughly investigated for 17 residents (#127, #101, #124, #125, #131, #132, #134, #122, #141, #76, #20, #148, #151, #154, #155, #152, #12). Following review of the facility's investigative findings for each of these residents, when asked for further evidence the allegations were investigated, the DON and/or the Administrator confirmed that there was no further information to support the allegations had been thoroughly investigated. Cross Reference F 610
4) The failure of the facility administration to have a process in place to ensure residents received medication as prescribed and ensure the administration of medication was accurately documented contributed to the determination that a condition of Immediate Jeopardy (IJ) existed.
Cross Reference F 684.
The facility staff failed to obtain an ordered medication for a resident with Human Immunodeficiency Virus (HIV) and a history of Hepatitis C for 23 days. During an interview with the Surveyor, Resident #99 reported that he/she had not received their medication, Triumeq since the resident's admission to the facility on [DATE] until he/she received it on 11/14/19. Review of Resident #99's medical record, pharmacy reports and multiple staff interviews confirmed the medication had not been available, so the resident had not received it for 23 days. Resident #99's November 2019 MAR revealed documentation that various nurses on various days documented the Triumeq as being given 50% of the time it when the medication was not available in the facility. On 11/21/19 at 11:36 AM, during a meeting with the survey team, the Director of Nursing, Administrator #2 and Administrator #3 were made aware of the findings of a multisystem breakdown that allowed the resident to not receive his/her medication for 23 days and made aware the facility staff documented the medication as administered 50% of the time it was not available. As a result of the findings an Immediate Jeopardy was declared on 11/21/19 at 1:36 PM. The facility submitted a removal plan on 11/21/19 around 4:00 PM, which the State Agency did not accept. An acceptable removal plan was accepted on 11/21/19 at 8:27 PM and the Immediate Jeopardy was removed on 11/27/19 at 1:54 PM.
5) The failure of the facility administration to have a process in place to ensure resident's wounds received care and treatment to promote healing, including, but not limited to ensuring resident wounds had treatment orders, wound assessments were documented weekly, infection control practices were followed to prevent the spread of infection, wound care supplies were available, wound consult reports were in the resident's medical record contributed to deficient practice that resulted in a harm. Cross Reference F 686.
a. Resident #101's medical record revealed documentation that the resident was being seen at the wound clinic weekly beginning on 6/17/19 for an abrasion on the resident's right buttock and indicated a wound treatment with Venelex ointment to the buttock abrasion twice daily. There was a wound consultant report on 7/18/19 and 8/13/19 that addressed the wound. The resident's TAR (treatment administration records) indicated the Venelex ointment was started in the facility on 6/24/19 and discontinued on 8/20/19. There was no documentation in the medical record to indicate the reason the ointment was discontinued, there was no evidence the resident's physician was aware it was discontinued. There was no further documentation found in the resident's medical record to indicate the resident was being seen weekly at the wound care clinic. The wound care clinic faxed over weekly consult reports. The 10/29/19 report documented the resident's buttock wound had re-opened and indicated the wound was to be treated with Venelex ointment twice a day. On 11/19/19 the consult report included an order for Venelex ointment to the right buttock wound twice a day. On 11/26/19, in a wound consult report, the practitioner again indicated that the resident's right buttock wound was to be treated with Venelex ointment. The medical record revealed the Venelex ointment was not ordered in the facility for treatment of the residents wound until 12/3/19. Also, there was no evidence a skin integrity report had been completed for the resident's buttock wound from 6/24/19 through 8/20/19, during the time the buttock wound was treated.
b. Resident #114's medical record revealed a 10/23/19 treatment order which addressed 3 wounds in one order. One area, the left superior buttock wound was noted to be healed on 11/13/19 and the order was not discontinued until 11/20/19. The medical record indicated that in November and December 2019, the resident was seen by the physician on 11 occasions and there was no documentation by the physician regarding the resident's wounds. Resident #114's admission skin sheet dated 10/22/19 and the Skin Integrity Reports initiated on admission indicated discrepancies between the 2 forms of documentation and review of subsequent skin reports revealed the staff failed to complete the full assessment of wounds on a weekly basis. During a surveyor observation of wound care provided to the resident by the CRNP (certified nurse practitioner) #20 and the ADON (assistant director of nursing) the CRNP #20 was observed to practice poor infection control practice by using the same ruler to measure the resident's wounds and using gloves that were pulled from the CRNP's scrub pockets. The CRNP #20 reported that the resident prescribed treatment product, Santyl, was not available and had to use a different treatment product.
c. Resident #17 medical record documented the resident had 4 wound areas when he/she was admitted to the facility on [DATE]. There was no documentation that for 3 weeks a weekly skin assessment had be done. Review of the resident's October and November 2019 TAR revealed the facility failed to perform dressing changes to the left heel, the right lower leg and the Sacrum every day as ordered.
d. Resident #36's medical record documented the resident was admitted to the facility on [DATE] with multiple wounds on his/her back. The resident had 3 skin integrity sheets initiated on 9/17/19 that addressed 5 areas, however, did not address the resident's buttock wound. An 11/15/19 abscess note documented on the sacrum and lower back. There was no further skin sheet documentation that tracked the progress of the resident's skin integrity and no skin sheet for a sacral wound. The resident was seen by the CRNP #20, who measured the wounds, 5 times between 9/18/19 and 11/6/19. There was no evidence the resident's skin integrity was being monitored and documented during the time the CRNP #20 did not see the resident. The DON confirmed the lack of skin monitoring.
e. Resident #82 had a skin integrity report dated 10/25/19 that documented the resident had a pressure ulcer on the right lower extremity and a progress note dated 10/25/19 that documented the resident had a pressure ulcer on the right inferior lower leg with purulent and malodorous drainage, indicating the wound could be infected. There was no documentation to indicate the physician or wound practitioner had been made aware of the wound assessment. During an interview with the surveyor, the wound nurse practitioner #29 confirmed he/she had not been notified about the wound.
6) The facility administration failure to ensure physicians reviewed the resident's total program of care, including an accurate assessment of a resident's wound, failure to ensure physician documentation was current and accurate, failure to ensure residents' wounds had treatment orders that were accurately written and the facility failed to ensure a resident attended weekly wound care clinic appointments contributed to deficient practice that resulted in a harm.
Cross Reference F 711
Resident #101's medical record revealed the resident had a right lower leg ulcer and was being seen at the wound care clinic once a week since 6/17/19. Wound care clinic consults reports indicated that the resident had not been seen in the clinic for 4 weeks, from 8/13/19 to 9/10/19. During that time, the care directed by the wound clinic was not provided.
On 8/20/19, in a progress note, the nurse indicated that the wound appointment would be rescheduled because the resident's wheelchair was too wide to fit in the transport van. There was no documentation in the medical record to indicate the facility administration attempted to arrange wheelchair accommodations or alternative transportation to ensure the resident attended his/her weekly wound care appointments. There was no documentation the resident's physician had been notified. The medical record revealed an 8/20/19 phone order that indicated the treatment for the resident's right lower extremity wound to be done on Mon, Wed and Fri as needed when the Unna Boot (compression gauze bandage) was not in place. There was no physician documentation of an assessment and evaluation of the resident's wound related to the dressing change phone order and as of 12/3/19 the telephone order had not been signed by the physician. On 8/20/19, in a progress note, the physician inaccurately documented that the resident had an above knee left leg amputation indicated in the resident's past medical history that the resident had both legs amputated and a wound on the right stump, which was inaccurate. Under physical exam, the physician indicated the resident had an open area on his/her small right toe and the physician's plan included care to a right ankle wound per the wound nurse. Review of the skin integrity reports revealed the resident's right toe wound was healed on 5/15/19 and the resident was not being seen by the wound nurse because he/she had weekly wound care clinic appointments. There was no evidence that the weekly wound consult reports were reviewed by the physician or the CRNP.
The wound consultation report dated 8/13/19 documented an assessment of the wound, the wound care treatment, the dressing change frequency and indicated that the dressing should not changed for one week. The resident was to return to the wound care clinic in 1 week. Additionally, there were instructions to not remove the dressing unless another Unna boot was put back on the resident.
During the 4 weeks that the resident was not seen at the wound care clinic, the resident's Unna boot dressing was not addressed, the facility failed to follow the 8/20/19 wound treatment order and the physician/CRNP failed to assess the address the care of the resident's wound. When the resident returned to the clinic on 9/10/19, maggots were found in the wound and the wound was found to be infected as documented in the 9/10/19, and 9/17/19 wound consultation reports. On 12/4/19 at 1:05 PM, the medical director was made aware of the findings and indicated that pre-templated progress notes are utilized by staff contributed to the erroneous data for Resident #101.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 17) During an interview with Resident #42 conducted on 11/19/19 at 9:20 AM revealed that he/she was transferred to the hospital ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 17) During an interview with Resident #42 conducted on 11/19/19 at 9:20 AM revealed that he/she was transferred to the hospital in November 2019 and returned the same day. However, review of the transfer form completed by Registered Nurse #18 on 11/19/19 revealed that the resident was transferred in June of 2019 and returned in November 2019.
The Director of Nursing confirmed surveyor's findings on 11/19/19.
14) On 11/18/19 at 12:16 PM, during an interview, Resident #32 stated that he/she occasionally smoked cigarettes and held his/her own smoking material. On 11/25/19 at 11:26 PM Resident #32's medical record was reviewed. Review of Resident #32's care plans revealed a care plan, Patient may smoke independently per smoking assessment, with the goal Patient will smoke safely x 90 days. Continued review of Resident #32's medical record revealed a 10/20/19 Smoking Evaluation Form that documented that Resident #32 was not safe to hold a cigarette, not able to light a cigarette, not able to properly dispose of ashes or butts, could not smoke safely without the use of a smoking blanket, and, required supervised smoking. The smoking assessment was in contradiction to the resident's care plan which indicated Resident #32 was safe to smoke independently.
On 11/25/19 at 1:12 PM, the DON was made aware of these findings and stated Resident #32's smoking care plan was accurate and the smoking assessment was totally wrong. The Director of Nurses (DON) stated that he/she had observed Resident #32 smoking and the resident could safely hold a cigarette, safely smoke and safely extinguish a cigarette.
Continued review of Resident #32's medical record revealed a 10/24/18 physician's order for Methadone (medication to treat addiction) that failed to clearly identify the dose of medication that the resident was to receive. Review of Resident #32's November 2019 MAR (medication administration record) revealed an order for Methadose (Methadone) 40 mg (milligrams). Give 1.75 tablet by mouth one time a day for substance abuse. Give 1.75 tablets to equal 60 mg, dissolve in water. Please go by the date that is on the bottle from clinic. The order to give 1.75 (1-3/4 tablets of 40 mg strength tablets to equal 60 mg was inaccurate as 1.75 tablets of 40 mg strength tablets equal 70 mg. 1.5 tablets of 40 mg would equal 60 mg). The order failed to clearly identify if the dose of methadone was 60 mg or 70 mg.
The DON was made aware of these findings on 11/26/19 at 12:20 PM.
Cross Reference F 760.
15) On 11/20/19 at 11:07 AM, Resident #19's medical record was reviewed and revealed a care plan that was identified as another residents care plan was in Resident #19's electronic medical record The care plan, initiated on 3/16/19, had the focus GDS 4 [other resident's name] has impaired/decline in cognitive function or impaired thought process with a global deterioration score of 4 related to: Alzheimer's disease or other cognitive loss/dementia.
16) On 12/2/19 at 10:55 AM, review of Resident #10's medical record revealed Resident #10 had a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder, inserted through an incision in the belly). On 11/1/19, in a urology consult report, the physician wrote to change resident's suprapubic tube every 4 weeks and indicated a 16 French (Fr.) (size) catheter should be used.
Review of Resident #10's November 2019 TAR (treatment administration record) revealed a 11/8/19 order to change the resident's suprapubic catheter every 4 weeks with a 16 Fr. catheter which was signed off as being done on 11/8/19. Continued review of the TAR revealed a 9/10/19 order for Suprapubic catheter, 14 Fr. to bedside straight drainage for urinary retention & chronic sacral wound which was signed off every shift except 1 (11/30/19, 11-7) for 30 days in November 2019, indicating the size of Resident #10's suprapubic catheter was a 14 French which was in contradiction to the order for a 16 Fr and the documentation that a 16 Fr. Suprapubic catheter had been inserted on 11/7/19.
The Director of Nurses (DON) was made aware of these findings on 12/3/19 at 9:40 AM.
11) Resident #71's medical record was reviewed on 11/25/19 at 10:03 AM. His/her physicians orders included but were not limited to:
A) Milk of Magnesia (MOM) Suspension give 30 ml (milliliters) by mouth as needed for Constipation give at bedtime if no BM (bowel movement) in 3 days.
B) Dulcolax Suppository 10 mg rectally as needed for constipation, if no results give Miralax by next shift.
C) Fleet Enema insert 1 dose rectally as needed for constipation if no result from Dulcolax within 2 hours. If no results from Fleet enema call MD/APP (physician/advanced practice provider) for further orders.
The physicians orders were not clear as to when the Dulcolax suppository should be given to the resident. The resident did not have a physician's order for the Miralax referred to in the Dulcolax suppository order.
During an interview on 12/3/19 at 12:47 PM Staff #8, a Unit Manager was asked to review and explain the resident's medications for constipation. She indicated that the Fleet enema would be given when nothing else worked and that the MOM should be given first because it specified if no BM in 3 days. When asked when the Dulcolax suppository should be given she indicated the order did not clearly indicate when it should be given. She confirmed that Resident #71 had no order for Miralax.
The Director of Nursing was made aware of these findings on 12/3/19 at 2:17 PM.
12) Resident #4's medical record was reviewed on 12/3/19 at 2:19 PM. The Physicians orders included but were not limited to:
A) Milk of Magnesia (MOM) suspension give 30 ml by mouth PRN (as needed) for constipation give at bedtime if no BM (bowel movement) in 3 days.
B) Dulcolax suppository 10 mg PRN for constipation if no result from MOM by next shift.
C) Fleet enema PRN for constipation if no result from Dulcolax within 2 hours, if no results from the enema call the physician/practitioner for further orders.
D) Colace Capsule (stool softener) 100 mg give 1 capsule by mouth every 12 hours PRN for bowel regimen. The order did not indicate when the Colace should be administered to the resident.
The Director of Nursing was made aware of these concerns on 12/6/19 at 11:07 AM and confirmed that the order was not clear.
13) Resident #58's medical record was reviewed on 12/5/19 at 9:35 AM. The resident was admitted [DATE]. The resident's weights were recorded in his/her electronic medical record as:
10/2/19 - 162.8 (total lift)
10/7/19 - 160.6 (total lift)
10/24/19 - 144.4 (total lift)
10/25/19 - 155.5 (wheelchair)
11/5/19 - 150.2 (wheelchair)
11/13/19 - 141.0 (wheelchair)
11/18/19 - 137.2 (wheelchair)
11/19/19 - 137.2 (wheelchair)
11/26/19 - 139.8 (wheelchair)
12/3/19 - 142.4 (wheelchair)
Each weight from 10/24/19 through 12/3/19 included a warning related to the residents weight change.
The record contained 22 physicians progress notes and 4 Certified Registered Nurse Practitioner (CRNP) progress notes written between 10/2/19 and 12/2/19. Every progress note stated: Appetite satisfactory. No significant weight change.
The physician progress notes included the residents weight measurements. The 14 physicians progress notes written between 10/24/19 to 12/2/19 included a warning indicating there was a weight change, the percentage of the weight change and the word False.
On 12/6/19 at 11:07 AM the Director of Nursing was made aware of the documentation in the practitioners progress notes of No significant weight change, and labeling the resident's weights as False She confirmed these findings but was unable to identify why the weight's would be labeled False.
Cross reference F 580
5) Review of the medical record for Resident #119 on 12/2/19 revealed a skin sheet for the left heel which was initiated on 3/27/19 which documented the resident had a pressure ulcer. Review of a wound consult by CRNP (Certified Registered Nurse Practitioner) #20 on 3/6/19 documented the resident had a DFU (diabetic foot ulcer).
6) Review of Resident #36's medical record on 12/5/19 revealed the resident was admitted on [DATE] from an acute care hospital with multiple wounds on the back. Skin sheets were initiated on admission, however there was no further documentation on the skin sheets following admission. A note of 11/15/19 documented a stage 2 pressure ulcer on the sacrum, however there was no skin sheet for the pressure ulcer with a description of size, color, appearance. The resident was followed by CRNP #20, a wound care specialist, and the only measurements of the wounds were done on the days the CRNP saw the resident, which were on 9/18/19, 10/16/19, 10/23/19, 10/30/19 and 11/6/19. The facility failed to accurately document the wound progress.
Discussed with the Director of Nursing on 12/5/19 at 3:30 PM who confirmed the lack of skin monitoring.
7) On 11/26/19 Resident #122's medical record was reviewed and a 7/15/19 Discharge Plan Documentation Form revealed nursing documentation which stated, skin intact, walking - independent and equipment needed was blank.
Resident #122 was admitted to the facility in May 2019 post bilateral left and right below the knee amputation. The resident had a treatment order, cleanse right stump then apply silver alginate cover with dressing. Silver alginate is a wide range of non-antimicrobial wound dressings that are used for managing non-infected chronic wounds. They promote wound healing by generating and maintaining a moist environment. Alginate wound dressings are the best example that are used in the management of exudating (oozing) wounds. Resident #122's skin was not intact.
A 7/1/9 social service note documented, enjoys autonomy of locomotion via wheelchair. His/her goal remains to return home when his/her wound is manageable or healed. The resident did not ambulate.
8) Review of Resident #135's medical record on 12/3/19 revealed a February 2019 Medication Administration Record (MAR) that documented the resident was to receive Humalog insulin at 7:30 AM, 11:30 AM, 4:30 PM and 9:30 PM. Review of the February 2019 MAR documented on 2/2/19 that the 7:30 AM insulin was signed off as given at 14:35 (2:35 PM), the 11:30 AM insulin was signed off as given at 14:40 (2:40 PM) and the 4:30 PM insulin was signed off as given at 23:41 (11:41 PM) by RN #64.
On 12/4/19 at 10:37 AM the DON stated that RN #64 was an agency nurse and confirmed the RN did not sign off the insulin when given and the nurse had been terminated.
9) Review of the medical record for Resident #136 revealed the resident was discharged from an acute care facility and admitted to the facility on [DATE]. The discharge summary from the acute care hospital had a list of 7 medications that the resident was to take which included the medication docusate-Senna 50mg-8.6 mg (2) tablets by mouth twice per day. Docusate-Senna is a stool softener and laxative.
Further review of Resident #136's medical record failed to have the medication listed in physician's orders, failed to have the medication on the August 2019 MAR and failed to have the medication documented in the computer system. There was no documentation found in the medical record which indicated the attending physician did not want the resident to have the medication.
On 11/21/19 at 11:15 AM RN #39 was interviewed about the process of admitting a resident and reconciling medications. She stated, we will read off the meds from the discharge summary to the physician. When asked what if a physician doesn't want a medication administered, she stated that they will discontinue it in the computer or write no next to the medication on the discharge summary. The surveyor asked, if there is nothing written on the discharge summary and if the medication in not in the computer system would you say that the medication was missed? RN #39 responded, yes.
There was no documentation in the medical record as to if the resident was to receive the docusate-Senna or not to receive.
10) Review of the medical record for Resident #145 on 12/9/19 revealed a nursing note dated 10/18/18 at 15:49 which stated, patient is having difficulty eating due to decreased appetite. Pt. is drinking Glucerna for supplementation. A 10/20/18 at 14:58 nursing note documented, providing supplements.
On 12/9/19 at 10:04 AM the surveyor asked the NHA if someone could locate an order for the TID (3x/day) supplement, where it was documented and how much the resident consumed. On 12/9/19 at 10:40 AM the NHA brought the dietician nutritional assessment and confirmed there were no physician's orders for the supplement, which she was assuming was Ensure, and she confirmed that there was no documentation as to how much supplement was consumed. She also confirmed that the dietician and other staff no longer worked at the facility, therefore she could not ask them.
3) On 11/19/19 at 8:19 AM Nurse #66 reported she worked for an agency and that she would be administering medications once she was able to get access to the [electronic health record (EHR)] system.
The unit nurse manager #5 confirmed this was Nurse #66's first day at the facility. At 8:26 AM Nurse #66 was observed on the phone. At 8:40 Nurse #66 remained on the phone, she confirmed she still did not have access to the EHR. The nurse went on to report that she arrived at 7:00 AM, at 7:45 AM she was informed that she would have EHR access in 15 minutes. At 8:58 AM Nurse #66 was unable to gain access to the EHR. At 9:04 AM Nurse #66 was again on the phone attempting to get EHR access.
On 11/19/19 at 9:11 AM Nurse #66 reports she now had EHR access and begins preparing medication pass.
On 11/19/19 at 9:50 AM the Director of Nursing (DON) reported that she is responsible for ensuring newly arrived agency staff have access to the EHR. She went on to report that she had been on the unit earlier and denied that she had been informed that the nurse did not have access, stating she can obtain access in 15 minutes. Surveyor then reviewed the observation, with the DON and the Administrator #2, of the nurse not having access to the EHR for an hour.
4) On 11/19/19 review of the Resident #110's medical record revealed the resident has a history of dementia, failure to thrive, chronic kidney disease, high blood pressure, diabetes and lung disease. The resident has had a g-tube since 2018 although the resident does consume meals by mouth.
Further review of the medical record revealed an order, dated 10/25/19, for 1 can Jevity 1.5 (237 ml) via PEG [g-tube] to be given after meals at 10:00 AM; 2:00 PM and 7:00 PM.
On 11/19/19 at approximately 2:45 PM review of the medical record revealed documentation that Nurse #40 had administered the Jevity on 11/19/19.
On 11/19/19 at 3:04 PM Nurse #40, who had been assigned to care for the resident during the day shift, reported the resident was a feeder [a resident in need of assistance with eating]. When asked if the resident received all nutrition by mouth, the nurse reported: yes. The nurse went on to report if the resident doesn't eat up to 50% he would give the resident a bolus [can of feeding via g-tube]. He confirmed that he had not administered any Jevity today, stating the resident has been going over [the 50%] for eating.
When surveyor reviewed with Nurse #40 that the documentation revealed that the resident was to receive one can of Jevity after meals and that he had documented the administration of the Jevity the nurse reported that he would have to strike it because the resident ate and he did not give the Jevity. He confirmed that he did not administer the Jevity in the morning either. On 11/19/19 at 3:09 PM the nurse was observed reviewing the orders in the electronic health record and stated looks like they changed the order, how they had [him/her] was if [he/she] eats over a certain amount we don't give the bolus, when I work with [the resident] that is how it's been. The nurse went on to report that he was employed by an agency and usually works on this unit or the rehab unit.
On 11/19/19 at 3:28 PM surveyor reviewed the concern with the DON regarding Nurse #40's documentation that the Jevity had been administered despite his report that the resident does not receive the Jevity unless the resident eats less than 50% of meals and confirmation that he had not administered the Jevity on 11/19/2019.
Further review of the TAR and the nursing notes revealed that Nurse #40 documented that the 11/19/19 Jevity was administered at 10:00 AM.
Based on medical record review, interviews and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards as evidenced by: 1) failing to ensure the accuracy of physician and certified nurse practitioner notes (Resident #101); 2) professional nursing staff signing off that a treatment was performed when it was observed not to be done (Resident #20); 3) failure to ensure nursing staff had access to the electronic health record in a timely manner; 4) staff documenting the administration of g-tube feeding when it was not actually administered (Resident #110); 5) failing to ensure that PRN (as needed) medication orders clearly indicated when they should be given for 2 of 7 residents (Resident #71 and Resident #4) reviewed for unnecessary medications; 6) failing to ensure that a resident's weight loss was accurately reflected in the practitioners progress notes for 1 of 5 residents (Resident #58) reviewed for Nutrition. This was evident for 16 of 104 residents ( Resident #101, #20, #110, #119, #36, #122, #135, #136, #145, #71, #4, #58, #32, #19, #10 and #42) reviewed during the annual survey.
The Findings Include:
1) Review of Resident #101's attending physician's notes dated 7/17/19, 8/2/19, 8/5/19, 8/10/19, and 8/20/19 all revealed inaccurate data. It is noted that Resident #101 had an above the knee left leg amputation in December of 2018 and the resident was noted with a chronic wound/ulcer on the lower right leg. The physician's notes under Past Medical History indicated the resident had bilateral leg amputation and wound right stump. Under Physical Exam, the physician's notes indicated the resident had an open area small right toe. Review of skin integrity reports indicated that the right 2nd toe area was healed on 5/15/19. Under the plan section the physician wrote local dressing care of wound right ankle per wound nurse. The resident was not being seen by the wound nurse as the resident was to have weekly visits at the wound clinic.
Review of a certified registered nurse practitioner (CRNP)#21 notes dated 7/25/19, 8/23/19, 8/29/19 revealed inaccurate data for Resident #101. Under past medical history section of the note revealed the resident had bilateral leg amputation and wound right stump. Under the history of present illness and the physical exam section both indicated that the resident was [AGE] years old. On the dates the notes were written Resident #101 was [AGE] years old.
Under the physical exam: skin section on all three notes revealed the following; Right leg wound 7 x 4 x 0.2. 100% necrotic. Periwound is intact. Mod drainage. Slight odor. An interview was conducted with CRNP #21 on 12/4/19 at 2:45 PM. When shown printed copies of her notes she had indicated that she does not even see much of what is printed out. She revealed that she did not know that the past history section indicated that Resident #101 had bilateral amputations and the wound stump was listed on the right side. When shown the identical measurements of the right leg wound, she indicated that she did not provide those measurements and revealing that she did not assess or evaluate the wound.
Review of CRNP #35 notes dated 8/16/19, 8/22/19, and 8/27/19 indicated the same inaccurate data under the past medical history section indicating the resident was a bilateral amputee with a right stump. Under the plan section it was documented the same as the attending physician's note as local dressing care of wound right ankle per wound nurse.
The medical director was informed of the concerns on 12/4/19 at 1:05 PM. The medical director indicated that the facility's corporation makes the staff utilize pre-templated progress notes.
2) Observation was made of Resident #20 on 11/15/19 at 9:02 AM. Resident #20 was lying in bed; the head of the bed was noted to be approximately at a 45-degree angle. The resident was wearing a nasal cannula (a lightweight tube that is hooked onto an oxygen concentrator that delivers oxygen to a resident who needs respiratory help). The nasal cannula was hooked onto the oxygen concentrator and was delivering 3.0 liters (L) of oxygen. Resident #20 was observed again with a second surveyor at 2:27 PM on 11/15/19 and was receiving oxygen at the same rate of 3.0 L.
On 11/15/19 at 2:45 PM, a review of Resident #20's TAR (treatment administration record) revealed an order for oxygen at 2 L/min continuous and was documented as done at that time. The order on the TAR was originally prescribed on 1/18/19.
At 3:19 pm the Director of Nursing (DON) was asked to make a copy of Resident #20's November 2019 TAR. Upon receipt of the copied TAR the DON was advised of the incorrect oxygen flow and failure of the staff to accurately document oxygen administration.
Review of Resident #20's November 2019 physician orders on 11/15/19 revealed orders written as Medigrip size E socks BLE (bilateral lower extremities) cut to fit legs from bottom of toes to top of calf. Apply every day on Q (every) am off Q hs (hour of sleep/bedtime) every shift and Prevalon Boots to BLE while in bed every shift. (Prevalon pressure-relieving heel protector features pillow-style cushioning and is made with ultra-soft, open-weave fabric.) Resident #20 was observed by two surveyors at 2:27 PM on 11/15/19 and did not have the prescribed treatments applied to his/her lower extremities. On 11/15/19 at 2:45 PM, a review of Resident #20's TAR (treatment administration record) revealed both skin treatment orders to bilateral lower extremities were documented as done/applied.
Continued observations were made on 11/18, 11/19, and 11/20/19 at the end of each day shift. The two skin protecting devices were not observed on Resident #20 lower extremities. On 11/19/19 at 09:57 AM interview of Resident #20, indicated/stated that s/he has not worn the boots (Prevalon) in a long time. Review of the TAR on 11/20/19 at 3:30 PM revealed that both orders were signed off as applied on 11/18 and 11/20/19 without any further documentation.
With ongoing daily reviews of Resident #20's medical record, it was noted that there were two prescriptions to clean the filter on the oxygen concentrator on every Sunday day shift and on every Wednesday night shift. On the morning of Thursday 11/21/19 observations of the filter on the side of the oxygen concentrator was observed with build up dust on and around the perimeter of the filter. The TAR was signed off as done/performed by the night shift staff for the previous night shift.
On 11/21/19 at 1:04 PM interview of the Licensed Practical Nurse (LPN) #6 assigned to Resident #20 was interviewed. She was in the resident's room and acknowledged that the protective skin treatments were not on the resident's lower extremities. She indicated that Medigrips are in a roll and that they are to be cut from the roll and applied each morning. The nurse confirmed that the Prevalon boots were not in the resident's room. She searched for a box of the Medigrip size E and was unable to find any on the unit. The nurse did find an open box of the Medigrip size F to show the surveyor and she provided instructional information as the how to apply the product as prescribed.
At 1:47 PM on 11/21/19 the unit manager #5 was informed that staff have signed off as applying the Prevalon boots on all three shifts for the month of November 2019 except for day shift of 11/19/19 and the prescribed Medigrip sox were signed as applied every day shift except for 11/8/19 and 11/19/19. The Prevalon boots were not observed on the resident or in the room based on observations between 11/15 and 11/21/19. The filter to the oxygen concentrator was pulled off to show the build up dust around the sides of the sponge like filter and that staff sign off twice per week as performing a cleaning of the filter without evidence of the filter being cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on employee interview, and observations, it was determined that the facility failed to ensure that the building was safe, clean and in good repair. This was identified in multiple residential, e...
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Based on employee interview, and observations, it was determined that the facility failed to ensure that the building was safe, clean and in good repair. This was identified in multiple residential, employee service, and public areas throughout the building but not limited to the stated findings.
The findings include:
Interview of the maintenance director on 12/6/19 at 12:00 PM acknowledged/confirmed that residents have access to the basement level of the building via the two facility elevators. The safety of residents on the basement level was discussed as related to items stored in the hallway and lack of supervision. The maintenance director confirmed that there is not any staff down on the basement level during the overnights. The basement level included offices for health information, nurse practitioners, activities, assessment coordinators, maintenance, housekeeping and human resources. Additionally, the laundry department, and the employee break room were located on this level.
Observations were made multiple times during the survey with storage of a bed, air conditioner unit, wooden doors, a safe on a dolly, and drywall sheets leaning against walls in the basement corridor/hallway noted on 12/6/19. Across from the back elevator there was exposed metal corner bead (approximately 2 to 3 feet length) exposed and separating from the wall at the corner juncture leading towards the basement exit. Much of the walls along the corridor were unfinished/unpainted/missing wallpaper exposing discolored plaster/wall board. There were multiple areas of missing cove/base molding and/or separating and bunched on the wall. Extensive dirty/grimy stained flooring noted in the corridor. The restroom around the corner of the front elevator was noted with strips (floor to ceiling) of missing wallpaper and with loose seam separating hanging wallpaper.
Cross reference to F-tag 584
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
2) Review of Resident #369's medical record revealed the resident was severely cognitively impaired and required supervision with meals. On 11/15/19 at 8:56 AM the resident's representative reported h...
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2) Review of Resident #369's medical record revealed the resident was severely cognitively impaired and required supervision with meals. On 11/15/19 at 8:56 AM the resident's representative reported having met with kitchen staff regarding items the resident does not like but expressed concern that the resident continued to receive some of these items. Observation of meal ticket on tray at this time revealed apple juice was listed as a dislike, apple juice appeared to be on the tray.
On 11/19/19 at 1:36 PM resident was observed eating lunch. The drink on the tray appeared to be apple juice. GNA #67 confirmed that the fluid in the resident's cup was apple juice. Surveyor observed that the drink cups were filled on the unit, rather than being delivered with the trays.
On 11/19/19 at 1:49 PM GNA #67 cleared the resident's tray from the table, surveyor noted that most of the apple juice remained in the cup at this time. The GNA #67 confirmed that the diet sheet listed apple juice as a dislike but that the resident was served apple juice with lunch.
On 12/5/19 surveyor reviewed the concern with the Director of Nursing and the Administrator regarding the failure to ensure preferences were communicated to and followed by staff serving meals.
3) Review of Resident #82's medical record revealed the resident was alert and oriented without cognitive impairment.
On 11/15/19 at 1:21 PM Resident #82 expressed concern regarding the melon that had been served for lunch reporting it was too hard to eat. The resident was observed holding the piece of melon between two fingers and was unable to mush the melon.
Based on resident council complaints, resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature, food that was palatable as evidenced by fruit which was too hard to eat and failed to ensure all ingredients were available and food was served attractively. Complaints and concerns made by multiple residents throughout the facility and a failed test tray were identified on the unit that was served food last (4th Floor) and found to be evident for 7 out of 10 residents (Resident #219, #99, #49, #32, #63, #369, #82) reviewed for concerns regarding food.
The findings include.
1) Random food complaints from residents included: On 11/14/19 at 3:04 PM Resident #219 stated that the food is cold. During an interview with Resident #99 on 11/15/19 at 10:35 AM, the resident reported that the food was cold, the tray had missing items, and lunch was usually served as late as 2:00 PM. At 1:13 PM on 11/15/19 Resident #49 indicated that he/she must be fed, food is brought into his/her room and left, and the food is served cold. On 11/18/19 Resident #32 indicated that the food is usually cold when he/she eats in room, he/she does not understand why the food is not hot as we get served first upstairs and if I got food that was actually hot I would go into convulsions.
Review of the resident council minutes and departmental response forms from the previous 5 months revealed complaints of cold food as evident in the following statements: Dated 6/7/19 = Residents would like to receive hot meals, instead of cold one, when their food is being delivered to their rooms. Dated 7/5/19 = Residents mentioned that they are still not receiving hot meals on the unit. Patients have noticed the meal carts on the units on time, but staff will not deliver until sometime later which makes food service cold. Dated 9/6/19 = Residents talked about their meals are cold when they get it. Dated 11/1/19 = Breakfast on Friday - many complaints (very cold) . [resident name] was told someone would bring him a bowl of hot cereal and never returned. They all mentioned it was very cold.
Observations on 11/15/19 at 1:10 PM, the second meal cart arrived on the 3rd floor. The cart was pushed off the elevator and left unattended. The plate of food for Resident #63 was wrapped in plastic (Glad/Saran) wrap and sitting atop the food cart. When the staff did open the cart there was at least 8 other plates of food only wrapped in plastic wrap and no type of plate insulator. Resident #63's meal was delivered to the resident room at 1:26 PM. As the resident began to eat his/her meal, the surveyor asked the resident about the food and Resident #63 responded that the food was cold.
On 11/20/19 at 12:27 PM lunch time meal service observations were initiated in the kitchen. The tray line service had not started. The main entrée for lunch was listed on the menu as Philly Cheese Steak Sandwich, chicken noodle soup, garlic tater tots, parsley garnish, and shortbread cookies. A member of the dietary staff was observed to be taking and recording food temperatures. The temperature of the steak and cheese mixture was observed to be 170 degrees Fahrenheit (F). The plate warmer was on with two stacks of plates each with approximately 20 plates above the top rim of the warmer. The plate warmer was located approximately 20 feet from the tray line. Stacks of plates would be transferred over to the tray line stacked in a shallow pan as the tray line service was initiated.
At 12:37 PM the surveyor's Taylor made thermometer was calibrated in an ice bath.
Initially the cheese steak mixture was placed into a sub roll then placed onto an earthenware plate. The plate was covered with a hard-plastic insulator. The parsley garnish was not observed to be used on the prepared plates. As prepared trays are placed into transportation carts some of the plate insulators were observed to not tightly fit over/onto the plate and the soup was dished into reusable plastic insulated bowls with a disposable lid.
The tray line was temporally halted at 12:56 PM as the soup was being ladled into disposable paper cups with a disposable plastic lid from a pot on the stove. At 1:00 PM the 2nd cart for the third floor was started. At 1:07 PM the facility ran out of sub rolls and began using sliced white bread. They would lay two pieces of bread on the plate and place a rounded scoop of the meat/cheese mixture into the middle of the bread. At 1:09 PM they ran out of plates on the tray line. At 1:12 PM a stack of 11 plates came out of the dishwashing room. They were also out of the hard-plastic plate insulators and began using plastic wrap on the plates. At 1:16 PM the tray line was at a standstill as they needed more plates, and the soup was out again. One dietary employee was cooking more meat as the cheese/steak mixture was running out. As the three ladies on the tray line were waiting for food and plates, upon interview they indicated that running out of food is a common occurrence.
At 1:20 PM a new batch of cooked steak meat was brought to the tray line. At 1:21 PM 4 plates were delivered to the tray line. At 1:22 PM the test plate/tray was prepared, wrapped in plastic wrap and placed on a transportation cart. The cart was followed to the 4th floor, arriving at 1:29 PM. This was the 2nd fourth floor meal cart, upon arrival the first cart was noted to be full as it did not appear to have had any trays delivered.
Staff were observed passing out trays until the last resident was delivered food at 1:48 PM. The test tray was removed from the cart and taken to the fourth-floor dining/dayroom for temperature testing. The following temperatures were taken at 1:49 PM: The steak sandwich temperature was recorded as 102 degrees F. A sample of the steak sandwich revealed that there was not any cheese, tasted cold and bland without flavor. The tater tots temperature was recorded as 110 degrees F, they were mushy, and the plate felt cool to touch. The soup in the disposable paper cup temperature was at 102 degrees F and tasted lukewarm. The plate was not observed to have the parsley garnish.
A discussion was held with the former nursing home administrator (Staff #2) and the current nursing home administrator (Staff #3) at 4 PM to report the negative findings of food temperatures, and the kitchen running out of food and dishware including plates, bowls, and plate covers.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0625
(Tag F0625)
Minor procedural issue · This affected multiple residents
2) On 11/19/19 at 10:09 AM, review of Resident #13's medical record revealed documentation that Resident #13 was sent to the hospital on 8/9/19 for replacement of his/her GT (gastrostomy tube), which ...
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2) On 11/19/19 at 10:09 AM, review of Resident #13's medical record revealed documentation that Resident #13 was sent to the hospital on 8/9/19 for replacement of his/her GT (gastrostomy tube), which is a feeding tube. Review of the Bed Hold Notice & Authorization form, dated 8/10/19, that was sent to the resident's representative revealed documentation that Medicaid would pay for a bed hold for 15 days, which was inaccurate as Medicaid does not pay for hospital bed holds.
Based on medical record review and interview it was determined that the facility failed to provide accurate information in regard to the bed hold policy for residents receiving Medicaid. This was found to be evident for 2 of 8 residents (Resident #27 and #13) reviewed for hospitalization during the survey but had the potential to affect any resident with Medicaid discharged to the hospital.
The findings include:
1) On 11/15/19 review of Resident #27's medical record revealed the resident had been discharged to the hospital in August 2019. Review of the bed-hold policy documentation provided to the resident at the time of the discharge revealed documentation that the state Medicaid would pay for a 15 day bed hold. The state Medicaid program does not pay for bed holds.
On 11/19/19 at approximately 2:30 PM the Business Office Manager confirmed that Medicaid does not pay for a bed hold.
On 12/5/19 surveyor reviewed the concern that inaccurate information regarding Medicaid paying for a bed hold was being given to residents when discharged to the hospital with the Director of Nursing and Administrator, Staff #3.
Jul 2018
32 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that the facility failed to maintain residents' physical environment ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that the facility failed to maintain residents' physical environment in a clean and safe manner. This deficient practice has the potential to affect all residents, staff and visitors in the facility.
The findings include
1). During the initial tour of the facility on 07/12/18 at 9:10 AM, numerous gnats were noted at the 4th floor nurse station and in the room [ROOM NUMBER] by surveyor. At 9:34 AM surveyor noted gnats in and outside room [ROOM NUMBER] and at 10:21 AM, gnats were noted outside of room [ROOM NUMBER].
On 7/13/18 during unit dining service observations surveyors noted multiple gnats flying around in the hallways of all units and on food trays. Surveyors had also found multiple gnats in the conference room during the day.
During an interview with the Director of Nursing and Administrator on 7/13/18 at approximately 2:00 PM the Administrator revealed that earlier in the week, a bathroom toilet had broken on the 2nd floor and the leakage had also affected the main floor. It was a day or two later that staff started seeing the gnats.
The Administrator added that an exterminator was called out and was in the process of treating the building. However, on 7/16/18 at 10:29 AM gnats were noted by surveyor around the 4th floor's nurse station, in the conference room throughout the day and in various places in the facility daily during the survey.
2). During the initial tour on 7/12/18 surveyors found a variety of stains and missing rings on privacy curtains in rooms 201, 209, and in 220. In addition, the wall in the bathroom of 201 was dirty.
On 7/18/18 at 11:28 AM a facility observation and interview with Environmental Services Director (ESD) was conducted.
Observation of the 2nd floor unit employee restroom revealed wallpaper pulled off near the commode and several stained ceiling tiles. The ESD was asked how needed repairs in the facility were reported. She responded that staff would inform her, and she would enter the repair request in an electronic system (TELS) monitored by the facility corporate office. She went on to say that although she was aware of the needed repairs in the employee's restroom she failed to submit the repair request.
Further observation of the 3rd floor revealed loose baseboards in room [ROOM NUMBER], dusty debris in corners, dark stained ceiling tiles and walls in room [ROOM NUMBER]. Further observation revealed trash along with plastic gloves in a corner behind a trash can near the entrance of the room. Surveyor also noted that the employee bathroom on the floor contained multiple stained ceiling tiles.
During the observation, the ESD was directed to the rooms and made aware of the multiple privacy curtains observed by the surveyor team that were stained and/or in need of repair and acknowledged surveyors' findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on administrative record review and interviews with facility staff it was determined the facility staff failed to report allegations of abuse to the proper authorities and the facility failed to...
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Based on administrative record review and interviews with facility staff it was determined the facility staff failed to report allegations of abuse to the proper authorities and the facility failed to notify the state agency. This was evident for 1 of 13 abuse investigations conducted during this survey.
The findings include:
Review of facility reported incident #MD00127092 in which Resident #72 alleged that another Resident #59 entered his room at approximately 5:00 AM on 5/18/18 and got into his bed and fondled him while s/he was asleep.
Review of the facility's investigation revealed that geriatric nursing assistant #1 responded to a call from Resident #72 on 5/16/18 at approximately 7:30 PM, who yelled for assistance alleging that Resident #59 was in his/her room and fondled him/her.
Review of the grievance form submitted by Resident #72 on 5/18/18 revealed that the incident occurred 2 days prior on 5/16/18.
An interview was conducted with the Director of Nursing (DON) on 7/17/18 at 12:33 PM and s/he stated that GNA #1 worked for an agency and confirmed that the agency staff did not report to administration that the resident was found in Resident #72's room and the allegations of resident # 59 fondling Resident #72. Abuse was unsubstantiated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews with facility staff it was determined the facility failed to notify the resident a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews with facility staff it was determined the facility failed to notify the resident and or family representative in writing that they were being transferred out of the facility to the hospital. This was evident for 1 of 3 residents (#70) reviewed for hospitalization during the facility's annual Medicare/Medicaid survey.
The findings include:
A medical record review was conducted on 7/17/18 at 5:28 PM and it revealed that Resident #70 was hospitalized on [DATE] for right leg redness.
An interview was conducted with the Social Worker (SW) on 7/18/18 at 3:45 PM and s/he was asked if the resident and/or resident representative was notified in writing of the reason for the transfer/discharge to the hospital and was a copy sent to the Ombudsman. The SW stated, no. The SW stated that s/he was unaware that this was a requirement. The SW stated that s/he would make provisions moving forward, to ensure that this was completed accordingly.
The Nursing Home Administrator (NHA) was made aware of all concerns at the time of exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on review of recent facility discharge practices and interview with facility staff, it was determined that the facility failed to provide residents and or their representative (RP) with the prop...
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Based on review of recent facility discharge practices and interview with facility staff, it was determined that the facility failed to provide residents and or their representative (RP) with the proper paper documentation of the facilities bed hold policy. This was evident for 2 of 2 (#48 and #67) resident records reviewed regarding planned and unplanned hospitalizations.
The findings include:
1. Review on 7/17/18 at 9:07 AM revealed that Resident #6 was sent to the hospital on 3/23/18 diagnosis of osteomylitis (an infection of the bone) of the sacrum secondary to non-healing sacral ulcer requiring intravenous antibiotic management.
Interview with the facility Corporate nurse on 7/18/18 at 3:40 PM revealed confirmation that there was no documentation that the resident or RP was given a copy of the bed hold policy.
2. Review on 7/17/18 at 8:49 AM of Resident # 48's medical record revealed a hospitalization on 2/4/18 secondary to chest pain.
Further review on 7/18/18 at 9:31 of Resident #48's medical record failed to reveal evidence that s/he was notified of the facility bed hold policy at any time while the resident was hospitalized between 2/4-2/7 2018 or during the transfer.
Interview with the facility Corporate nurse on 7/18/18 at 3:40 PM revealed confirmation that there was no documentation that the resident or RP was given a copy of the bed hold policy.
The facility Administrator was notified of the findings during exit from the facility on 7/19/18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined facility staff failed to conduct a comprehensive assessment when a significant decline occurred in the Resident #21's condition. T...
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Based on medical record review and staff interview, it was determined facility staff failed to conduct a comprehensive assessment when a significant decline occurred in the Resident #21's condition. This was evident for 1 of 3 residents (#21) reviewed for a change in condition during this survey.
The findings include:
The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment directs the facility staff on issues that may need to be addressed.
Medical record review revealed Resident #21 was admitted to the facility with diagnoses that included but were not limited to Dementia, Left Leg Fracture, Muscle Weakness, Compression Fracture of the Thoracic Vertebrae, non-traumatic and Malnutrition.
Review of the admission MDS assessment with an assessment reference date 11/3/17 revealed facility staff coded the resident in Section G Functional Status G0110 A Bed Mobility, I Toilet Use, and J Personal Hygiene as a 3/2 (requires extensive assistance of 1 staff). Review of the quarterly MDS assessment with an assessment reference date of 1/25/18 revealed facility staff coded the resident in those care areas as a 3/3 (requires extensive assistance of 2 staff).
A social service note dated 1/12/18 reported the resident's BIMS score was 4/15. A physician's progress note, dated 1/26/18, reported the resident was evaluated to determine competency in decision making. A second certificate was completed noting the resident lacked adequate decision-making capacity due to Dementia. The first certificate, dated 1/18/18 noted the same.
Review of facility reported incident #MD00121634, on 7/16/18, revealed Resident #21 complained of left hip pain on 1/4/18 and 1/5/18. An x-ray of the hip done on 1/5/18 confirmed the resident had a fracture. The resident was transported to the hospital for treatment. The resident returned to the facility on 1/11/18 with staples and orders for wound care.
Despite noted changes and a decline in the resident's cognitive and physical condition in January 2018 the facility failed to complete a significant change MDS assessment.
During an interview with the surveyor on 7/19/18 at 9:55 AM Staff #6 stated changes in condition are discussed in morning meeting and s/he reviews change in condition documentation. Staff #6 stated the Change in Condition form dated 1/5/18 merely noted hip pain and an allegation of abuse, not a hip fracture. S/he acknowledge a significant change MDS assessment should have been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with the facility MDS (minimum data set) coordinator it was determined that Resident #73's MDS was incorrectly submitted regarding time in and out of facil...
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Based on medical record review and interview with the facility MDS (minimum data set) coordinator it was determined that Resident #73's MDS was incorrectly submitted regarding time in and out of facility. This was evident for 1 of 59 residents reviewed during the investigation portion of the survey.
The findings include:
The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD).
Review of the medical record of Resident #73 on 7/13/18 at 11:12 AM during the initial record review, revealed that Resident #73 had a transfer to the hospital on 6/5/18 with no admission and a return to the facility on the same day.
Further review revealed the resident was again sent to the hospital on the evening of 6/11/18 and returned to the facility on 6/12/18. This hospital visit was an overnight stay as the resident was in the hospital and not the facility after midnight on 6/11/18.
Review of the residents MDS on 7/16/18 revealed that the resident was coded as having a discharge (return anticipated) from the facility on 6/5/18 with a return on 6/12/18.
Therefore, according to the MDS the resident was not in the facility from 6/5/18 through 6/12/18.
Interview with the facility MDS Coordinator on 7/16/18 at 12:38 PM regarding the findings revealed that there must have been an error that the resident was not on the morning census list for 6/6/18. So when she reviewed the list and completed the MDS, she coded him/her as not in the building and as a discharge-return anticipated further coding the resident as not in the building until his/her return from the other hospitalization on 6/12/18. She stated that she would do a modification.
The facility Administrator and DON were notified of the findings on 7/16/18 at 3:14 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with facility staff, it was determined that the facility failed to develop care plans related to a residents hospice and end of life needs. This was eviden...
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Based on medical record review and interview with facility staff, it was determined that the facility failed to develop care plans related to a residents hospice and end of life needs. This was evident for 1 of 59 residents (#67) reviewed during the investigative portion of the survey.
The findings include:
A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress.
Review of the medical record for Resident #67 revealed admission to hospice services on 7/3/18.
Review of the residents medical record on 7/16/18 failed to reveal the presence of a care plan relating to the residents admission to hospice or end of life needs.
The Corporate nurse was interviewed on 7/17/18 at 5:06 PM and at that time reported to the surveyor that after her review there was no care plan from the facility or created directly from hospice services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on resident interview, record review and staff interview it was determined that the facility staff failed to start a wound treatment for Resident #90 as ordered. This was evident for 1 of 59 res...
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Based on resident interview, record review and staff interview it was determined that the facility staff failed to start a wound treatment for Resident #90 as ordered. This was evident for 1 of 59 residents reviewed during the investigation portion of the survey.
The findings include:
Negative-pressure wound therapy (NPWT) also known as a wound vac is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second- and third-degree burns.
On 7/16/18 at 9:45 AM an interview with Resident #90 was conducted. The resident shared that s/he had wound vac treatment stopped 2 weeks ago because a nurse said there were no supplies for it. S/he went on to say that they were informed a week ago that the wound, where the vac was located had worsened.
Review of the resident's medical record was conducted on 7/16/18. The resident had diagnosis that included peripheral artery disease, and non-healing left groin wound.
Review of the June 2018 hospital discharge record indicated that the resident was to have a wound vac for the left groin wound at the facility with the dressing to be changed every (Q) 72 hours. A review of the admission order revealed Negative pressure therapy Change every (Q) 72 hour However, review of skin treatment documentation for revealed that the treatments were done weekly and not every 72 hours.
In addition, a Nurse Practitioner's progress note dated 7 days after the resident's admission indicated that the resident's wound vac was loose and beeping and referred the resident's nurse for wound vac dressing change.
Review of a progress written by the Infectious disease physician (IDP staff #65) on 7/9/18 revealed that the resident stated the left groin wound vacuum had stopped working that morning and had an odor. The IDP also indicated that their exam revealed a left groin wound covered with malodorous yellow-grey slough under a loose/detached vac.
The wound vac order was discontinued on 7/11/18 by the resident's physician with a follow-up order written on 07/12/18 that referred vascular surgery for debridement of resident's left groin wound.
The Director of Nursing was made aware of surveyor's findings on 07/18/18 at 08:51 AM. She stated that she was responsible for staff training. She added that the wound vac company came out to in-service staff regarding the use of wound vac and stated that it was required that the staff had the training before admitting residents that required that specific skill.
Surveyor requested documentation to verify that staff was educated regarding the use and care of wound vacuums. However, during an interview with the DON on 7/18/18 at 2:44 PM she confirmed that although training was conducted there was no documentation to support that all the licensed nurses was educated regarding wound vacs confirming surveyor's concerns. (Cross Reference F 726)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on medical record review and interview it was determined that the facility failed to implement a resident's functional maintenance program (FMP) after discharge from physical therapy. This was f...
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Based on medical record review and interview it was determined that the facility failed to implement a resident's functional maintenance program (FMP) after discharge from physical therapy. This was found to be evident for one out of six residents (Resident #91) reviewed for activities of daily living during the investigative portion of the survey.
The findings include:
On 7/12/18 review Resident #91's medical record revealed an order dated 1/3/18 for the following: Physical therapy Clarification order: Patient is being d/c [discharged ] from skilled PT services to continue with FMP under nursing care. FMP and caregiver education completed at this time. Further review of the medical record failed to reveal any documentation regarding the FMP or it's implementation. At 10:46 AM surveyor requested documentation from Unit manager #35 in regard to FMP for this resident since no information could be found in the hard chart or the EHR. A copy of the Safe Transitions Goals/ Function Maintenance Plan was later provided by the unit manager. Review of this plan, dated 12/29/17, revealed documentation that 5 staff had been trained. The FMP included a Walking Program: Walk resident 100 feet bid [two times a day] using gait belt and wheeled walker.
On 7/16/18 further review of the medical record failed to reveal any documentation that the FMP walking program had ever been implemented for this resident. No documentation was found in review of the care plan about the FMP.
On 7/16/18 at 3:19 PM the Administrator reported that there was no formal restorative program at present, but they do train the staff. The Director of Nursing (DON) was not sure if the FMP were documented but stated that it might be in tasks. Tasks is the section of the electronic health record where the Geriatric Nursing Assistants document.
On 7/17/18 at 12:05 PM GNA #34 reported that sometimes the FMPs are put in the POC. POC is where the GNAs put their documentation of Tasks into the electronic health record.
On 7/18/18 at 11:20 AM the therapy director #7 reported that prior to the last day of therapy they start the FMP and educate as many GNAs as possible and the the unit manger if possible and a copy goes to the unit manager. She confirmed that the FMP should be put in the care plan but thought the nursing put it in. Therapy director also reported FMP included walking with the resident 100 feet bid with wheeled walker, and stated most likely the resident could do this upon discharge.
On 7/18/18 at 12:35 PM unit nurse manager #35 confirmed that the resident had been walking prior to a change in condition in March, stating that the spouse would come in a walk with the resident. The unit manager went on to report that she thought therapy puts the FMPs into the care plans. Surveyor then reviewed the concern that there was no evidence that the FMP was ever added to the Care Plan or the Tasks section of the POC and that therapy had reported they do not add the FMP to the care plans. The Unit Manager then confirmed that the care plan had not been updated to reflect the FMP that had been established in January.
On 7/19/18 at 12:25 PM the surveyor reviewed the concern with the corporate nurse #13 of the failure to implement the FMP in January and the failure to update the care plan at that time to reflect the FMP. The corporate nurse reported that no order had been written for the FMP.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and interviews it was determined that the facility failed to provide an ongoing activity program to meet the interests and support the psychosocial well-bei...
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Based on medical record review, observation and interviews it was determined that the facility failed to provide an ongoing activity program to meet the interests and support the psychosocial well-being of the residents. This was found to be evident for two out of two residents (#47) reviewed for activities.
The findings include:
Review of Resident #47's medical record revealed the resident had diagnosis which included dementia, high blood pressure and stroke. On 7/12/18 at 9:01 AM the resident was observed in bed awake but did not verbally respond to surveyor greeting, no tv, music or other activity was observed at this time. At 1:25 PM the resident was observed in bed with head under the cover, no music, tv or other activity observed at this time. On 7/13/18 at 9:17 AM resident observed in bed, staff arrived to remove breakfast tray, no tv, radio or other activity observed at this time; resident able to wave hello at this time.
On 7/13/18 at 10:35 AM the resident was observed in bed and the tv was on at this time.
On 7/16/18 at 1:06 PM the resident is observed in bed, resident awake and says yes to surveyor greeting. No tv or radio on at this time.
On 7/17/18 at 12:10 PM GNA #34 reported that the resident likes music so sometimes she turns the music on for the resident.
On 7/18/18 at 12:23 PM the resident was observed in bed with eyes shut, no music or tv on at this time.
On 7/18/18 at 2:24 PM resident is observed in bed with eyes shut GNA #36 reports the resident is not asleep, no tv or music on at this time. When asked, GNA #36 reported that the resident does have a radio but stated that it was not out right now, the GNA then proceeded to show the surveyor a radio found in the bed side cabinet.
Review of the activity care plan revealed an intervention to take the resident to music programs, but failed to include any interventions in regard to music in the resident's room.
On 7/18/18 at 3:28 PM the activity assistant #33 reported that she sees the resident for 1:1 visits, that the resident likes to be read to, and that the resident likes music and to sing. The activity assistant reported that she visits the resident twice a week, sometimes three but most of the time it's two and confirmed that she documents when she goes to see the resident.
On 7/18/18 review of the Resident Participation record for April/May/June/July 2018 failed to reveal documentation of any 1:1 or group activity from 5/27 thru 6/2 or from 6/10 thru 6/24. Documentation was found for only 19 days of activity intervention for the 13 week period since 4/13/18.
On 7/18/18 at 4:11 PM the activity director #4 reported that they would bring the resident to any kind of musical activity. Surveyor review the concern with the activity director that there was no documentation of any 1:1 interventions for several weeks between April and July; multiple observations in which no music was observed in the resident's room despite a radio being available and the failure of the care plan to include music in the resident's room as an intervention despite reports from nursing and activities that he resident is known to enjoy music. The activity director reported that her staff bring everything they need on a cart [into the resident's room].
On 7/19/18 at 12:25 PM surveyor reviewed with the corporate nurse #13 the concern regarding failure to provide activities to meet the resident's needs and failure to include music interventions in the care plan. As of time of exit on 7/19/18 no additional documentation had been provided regarding activity interventions for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview with staff and review of medical records, it was determined the facility staff failed to 1) provide appropriate treatment and follow the physician orders to address the...
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Based on observation, interview with staff and review of medical records, it was determined the facility staff failed to 1) provide appropriate treatment and follow the physician orders to address the treatment needs of a resident wound and 2) provide pain management. As a result, the resident experienced increasing pain. This was evident in 1 of 6 (# 75) resident in the investigation portion of the survey.
The findings include:
1) On 7/13/18 at 12:30 PM Resident #75 groaned and grimace during dressing changes, he/she reported knees are hurting too. The nurse (staff #35) replied that she gave the resident pain medication earlier, but the resident said it does not help Nurse #35 apologized to the resident and reported that she would be done shortly. During an interview with Nurse #35 on 7/13/18 at 1:00 PM after the dressing change, the surveyor asked if the resident gets pain medication before dressing changes and the nurse replied, not before the dressing changes but the resident does have an order for pain medication three times a day 9 AM, 1 PM and 5 PM.
Resident #75 medical records were reviewed on 7/16/18. This review revealed that the resident was admitted to the facility for long term care and with diagnosis which includes Peripheral vascular disease, also called PVD, refers to any disease or disorder of the circulatory system outside of the brain and heart, chronic leg ulcers and muscle weakness. Further review of the medical records reveal that the resident is being followed by the wound team.
Review of the wound practitioner note dated 7/11/18 reveal the following: Patient is seen f/u (follow up) multiple LE (lower extremity) wounds. He/she reports BLE (bilateral extremity) pain especially with dressing change. Review of the orders failed to reveal any change in the resident's pain management.
On 7/18/18 around 10:45 AM the wound team was doing rounds on the resident with wound. The surveyor asked the wound practitioner if she could observe wound care on Resident #75, she replied yes and that she would let the surveyor know when it was time. Later facility staff informed the surveyor that the resident would not be seen today by the wound team and that the nurse would do the dressing change.
As the surveyor observed the nurse do the dressing change the resident again began to moan. Nursing staff informed the surveyor that the resident got pain medication earlier, however, the surveyor did not observe staff ask the resident about pain management.
During an interview with the corporate nurse on 7/19/18 the surveyor explained her concerns that the resident was not getting any pain relief with dressing change and that the wound practitioner notes addressed the pain but failed to change the orders. The corporate nurse verbalized understanding and reported that the resident attending is in the building to examine the resident.
The corporate nurse informed the surveyor that the resident medication orders have been changed and that the resident will be getting pain medication 1 hour before each dressing change.
2) On 7/19/18 Resident #75's physician orders and medication administration records (MAR) and treatment administration records (TAR) were reviewed. This review revealed the following physician order: BLE 1) clean with cleaner, 2) crush Flagyl 500 mg and sprinkle to wound 3) Silvadene cream apply to gauze 4) apply alginate to legs 5) cover with Abd pad. 6) Change QOD and PRN (Every other day and as needed).
Review of the TAR revealed the following: BLE 1) clean with cleaner, 2) crush Flagyl 500 mg and sprinkle to wound 3) Silvadene cream apply to gauze 4) apply alginate to legs 5) cover with Abd pad. 6) Change QD and PRN (Every day and as needed). Further review of the TAR reveals that staff was changing the resident's wounds every day and not every other day as ordered. The resident was having pain every day with dressing change that the order was for every other day.
During an interview with the Director of Nursing (DON) on 7/19/18 she revealed that the facility has a list of do not use abbreviations due to error prone. She further revealed that QOD is on the list as is QD she stated that it should be written out such as every day or every other day.
All findings discussed at the survey exit on 7/19/18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on medical record review and interview it was determined that the facility failed to ensure a resident with visual impairment was seen by an opthomologist. This was found to be evident for one o...
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Based on medical record review and interview it was determined that the facility failed to ensure a resident with visual impairment was seen by an opthomologist. This was found to be evident for one out of one resident (Resident #33) reviewed for vision services.
The findings include:
Review of Resident #33's medical record revealed diagnosis of glaucoma which is managed with three different prescription eye drops administered daily. There was also an order, originally dated 11/25/17, for ophthalmology consult and treatment as needed.
On 7/13/18 at 12:53 PM the resident reported that s/he was suppose to have a follow up eye doctor appointment but did not know when.
Further review of the medical record revealed the resident was seen by an optometrist in January and May 2018. An optometrist is not a medical physician. Review of the 5/9/18 optometrist note revealed the following: Glaucoma primary open angle both eyes poorly controlled IOP [inter occular pressure] .Referral: Ophthalmology Consult.
Review of a 5/31/18 nurse practitioner note revealed the following: Glaucoma of both eyes, unspecified glaucoma type Chronic, stable, hx [history] of blindness, Continue with current regimen of eye drops per opthomology. Will need annual eye exam.
On 7/17/18 further review of the medical record failed to reveal any documentation that an opthamology appointment had been scheduled for the resident.
On 7/17/18 at 5:31 PM surveyor reviewed with Director of Nursing the concern regarding failure to have opthalmology appointment as indicated by the optometrist, the order for opthamology as needed, the resident report and the nurse practitioner's 5/31 note.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on administrative and medical record review and staff and resident interview, it was determined the facility staff failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on administrative and medical record review and staff and resident interview, it was determined the facility staff failed to provide the appropriate level of supervision for a vulnerable resident (Resident #10) who was determined to be an elopement risk, which resulted in the resident eloping from a medical appointment while in the community. This was evident for 1 of 5 residents reviewed for accidents during this survey.
The findings include:
Medical record review revealed resident #10 was admitted to the facility with diagnoses that included but were not limited to Schizoaffective Disorder, Diabetes and other chronic health conditions requiring ongoing treatment. The medical record contained two Physician Certifications Related to Medical Condition, Decision Making and Treatment Limitations dated 2/17/16 and 2/18/16 that indicated the resident lacked adequate decision-making capacity due to Dementia.
People with Schizoaffective Disorder experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - either bipolar type (episodes of mania and sometimes depression) or depressive type (episodes of depression).
Surveyor review of a facility reported incident, on 7/16/18, revealed that on 9/5/17 Resident #10, while on appointment with an escort, left the physician's office and was later found at a local food market.
Medical record review revealed a care plan, with an initiation date of 12/31/15, that addressed the risk for elopement. On 4/22/16 an intervention was added to utilize and monitor a security bracelet (part of the elopement management system).
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
A Hospital Discharge summary, dated [DATE], noted the resident was seen for worsening psychiatric symptoms and treatment non-compliance. The resident was noted to have early onset Dementia, Depression, was very paranoid and delusional and displayed aggressive behavior.
An Elopement assessment dated [DATE] noted the resident had a history of elopement and wandering.
Review of Staff #41's employee file revealed that on or about 4/5/17 s/he received instruction on elopement precautions that included, when escorting a resident, they are never to be left unattended.
Elopement is defined as a resident that is not pre-authorized to leave the agency or activity site but does so intentionally and the resident's location is unknown.
In a written statement, dated 9/5/17, Staff #41 reported that upon arrival to the physician's office they were informed that the resident did not have an appointment. Staff #41 documented that s/he and the resident were going to sit in the waiting area until transportation back to the facility arrived. During their wait Resident #10 expressed a desire to smoke at which time Staff #41 escorted her/him outside. Staff #41 reported that s/he waited for the resident in the doorway of the clinic. Staff #41 further noted s/he was unaware that Resident #10 was a wanderer.
During an interview with the surveyor, on 7/17/18 at 2:39 PM, Resident #10 recalled leaving the clinic on 9/5/17 to see friends. When asked where the escort was located while s/he smoked Resident #10 responded that the escort went inside the building while s/he stayed outside to smoke.
The facility failed to maintain supervision of Resident #10, who was determined to lack adequate decision-making capacity, while s/he was on an appointment with an escort. This resulted in the resident eloping from the physician's office creating the potential for harm for this physically and mentally compromised resident.
The findings were discussed with the Director of Nursing on 7/18/18 at 4:55 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with facility staff, it was determined that the facility failed to provide respiratory services according to physician orders for a resident with the prese...
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Based on medical record review and interview with facility staff, it was determined that the facility failed to provide respiratory services according to physician orders for a resident with the presence of a tracheostomy. This was evident for 1 of 1 resident (#86) reviewed for respiratory care in the investigation portion of the survey.
The findings include:
Interview and observation of Resident #86 on 7/13/18 at 11:57 AM revealed the presence of a tracheostomy along with respiratory equipment in the resident's room.
The Director of Nursing (DON) was interviewed on 7/16/18 at 4:15 PM regarding Resident #86. The DON was asked if a respiratory therapist was in the building and she stated no, the resident does her own care, however, a therapist does come in as needed. The notes were requested from the facility.
Review on 7/17/18 at 10:50 AM of the medical record for Resident #86 revealed diagnosis including chronic obstructive pulmonary disease (COPD), anxiety, and encounter for attention to tracheostomy.
Further review of the consults for respiratory care provided by the facility revealed a consult in 4/26/18 and 6/12/18. Review of physician orders for July noted to change disposable inner cannula as needed.
Resident currently uses a Shiley tracheostomy tube and according to the manufacturer website reviewed on 7/17/18 at 11:11 AM, the tubes should not be used for more than 29 days and should be replaced and discarded.
Further review of all the resident's respiratory consults revealed that respiratory services were only in 12/21/17 and 1/15/18 and not again until the 4/26/18.
During interview on 7/17/18 at 12:22 PM with the facility DON and Corporate Nurse, it was determined that during the facility transition to entering orders electronically in November of 2017 there must have been a transcription error as there was a physician order since 1/15/15 stating RHS (respiratory health services) to change trach every month. During the transition to entering orders electronically for this resident on 11/13/17, this order was not transcribed correctly and after 1/2018 the resident's tracheostomy was no longer changed monthly. The order was never discontinued, it was just not carried over.
Therefore, it was reviewed and determined in review with the DON and Corporate Nurse that Resident #86 did not have his/her trach changed in February, March and May.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
2. On 07/18/18 at 02:32 PM, a review of the facility's assessment was conducted. The assessment revealed that for the number of residents in the facility the staffing plan required 1- full time(FT) Di...
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2. On 07/18/18 at 02:32 PM, a review of the facility's assessment was conducted. The assessment revealed that for the number of residents in the facility the staffing plan required 1- full time(FT) Director of Nursing (DON), 1- FT Quality Assurance (QA) /Nurse Practice Educator (NPE), 3- Unit Assistant Director of Nursing (ADONs) and 1- charge nurse for each shift.
The facility assessment reflects the administration's evaluation of the resident population, staff competency, and resources required to meet the highest practicable physical, mental and psychosocial needs of the residents. Regarding staff competencies, the assessment identifies gaps in staff competencies that may potentially affect quality of care of residents.
Review of the facility's staff roster revealed that the facility did not have an assigned Quality Assurance/Nurse Practice Educator or an ADON for the Transitional Care Unit (TCU).
During an interview with the DON on 7/18/18 at 2:44 PM she confirmed the unoccupied positions. She added that she had taken on the responsibilities of the QA/NPE role for the past year but due to the extra obligations she had been unable to conduct the required nursing staff competencies. Because of this, she could not be certain that the facility's nursing staff were maintaining the skill set to care for the residents.
Based on review of employee files and interview with staff it was determined that the facility failed to ensure 1. newly hired GNAs demonstrated skills competencies prior to being allowed to work with residents, and 2. put a system in place to ensure that the nursing staff had the appropriate skill sets to provide nursing and related services to residents This was found to be evident while conducting one of the thirteen abuse investigations.
The findings include:
1. On 7/18/18 review of GNA #19's employee file revealed the GNA was hired in March 2018. Further review of the medical record failed to reveal any documentation of a skills assessment having been completed after hire and before the start of work with the residents.
On 7/18/18 at 10:11 AM surveyor informed the corporate nurse that no evidence of a skills assessment after hire could be found for GNA #19.
As of time of exit on 7/19/18 no evidence of a skills assessment had been provided for GNA #19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of medical and administrative records and staff interview it was determined the facility failed to: 1. maintain an accurate account of the controlled medication, Morphine Sulfate, to e...
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Based on review of medical and administrative records and staff interview it was determined the facility failed to: 1. maintain an accurate account of the controlled medication, Morphine Sulfate, to ensure consistent availability for a resident (Resident #62) with chronic pain, and 2) accurately account for Resident #367's Methadone. This was evident for 2 of 3 residents reviewed for controlled substance accountability during this survey.
The findings include:
Morphine Sulfate is a pain reliever (opioid) used to treat moderate to severe pain.
Methadone reduces withdrawal symptoms in people addicted to heroin or other narcotic drugs without causing the high associated with the drug addiction. Methadone is used as a pain reliever and as part of drug addiction detoxification and maintenance programs.
1) Medical record review revealed resident #62 was admitted to the facility with diagnoses that included but were not limited Neuropathy, Scoliosis, Congenital Hip Dysplasia, Spinal Cord Compression and Sacral Pressure Ulcer. Review of the May 2018 Medication Administration revealed the resident was receiving Morphine Sulfate twice daily for chronic pain.
Review of the Medication Administration Record for May 2018 revealed the resident did not receive 8 doses of Morphine between the period May 1, 2018 and May 6, 2018. Further review of the medical record revealed that on 5/1/18 at 12:49 PM facility staff documented the facility was waiting on delivery of Morphine and on 5/1/18 at 10:22 PM it was noted that delivery was in progress. On 5/3/18 at 1:08 PM it was noted the facility was waiting on delivery of the Morphine, on 5/5/18 at 10:15 PM and 5/6/18 at 9:39 AM the medication was not available.
Surveyor review of facility reported incident #MD00127006 on 7/18/18 revealed a concern that on 5/22/18 during the 7:00 AM- 3:30 PM shift Resident #62's Morphine was not available.
According to the facility's investigation Staff #43 signed a receipt for 30 Morphine Sulfate tablets on 5/19/18. A Pharmacy Shipment Slip noted 30 tabs of Morphine Sulfate were sent to facility for Resident #62 on 5/21/18 at 1:46 AM and was signed for by Staff #43 on 5/21/18 at 1:46 AM.
In a written statement Staff #44 reported that on 5/22/18 during medication pass the resident's Morphine was not available and it was necessary to get the medication from the emergency stock. A Controlled Substance Prescription form requested the pharmacy to dispense 60 tablets of Morphine Sulfate for resident #62.
Medical record review revealed a Medication Progress note dated 5/22/18 at 1:37 PM that reported Morphine Sulfate for chronic pain was not available. A Medication Progress note dated 5/22/18 at 11:21 PM also noted the medication was not available.
The facility failed to maintain a system of accountability for narcotics to ensure residents receive medications needed for pain control and comfort.
The findings were discussed with the Director of Nursing (DON) on 7/18/18 at 8:19 AM. The DON was unable to provide a rationale for the missed doses of Morphine on 5/1/18, 5/3/18, 5/5/18 and 5/6/18.
Refer to F610
2)The facility failed to accurately account for Resident #23's Methadone.
Medical record review revealed resident #23 was admitted to the facility for skilled nursing care. The record contained an order for Methadone 57 milligrams (mg).
Review of facility reported incident MD00120438 on 7/17/18 revealed an allegation of misappropriation of narcotics. Review of the facility's investigation revealed that the missing narcotics included a bottle of Methadone prescribed for Resident #23.
Refer to F607
3) The facility failed to maintain a system of accountability for Oxycodone to ensure ongoing pain control for Resident #368.
Review of facility reported incident #MD00120438 revealed a concern that Resident #368 did not receive pain medication that was documented as administered on 9/21/17. During the narcotics count one Oxycodone IR 10 mg was missing. The oncoming nurse, Staff #47 signed that the count was correct at 3:00 PM.
The medication was never found. Staff #46 reported that several narcotics counts were off. Review of a Drug Diversion Reporting Form revealed that on 9/21/18, one bottle of Methadone and 3 tablets of Oxycodone were missing. It was further noted that it was discovered that the medications were missing during the count of the narcotics on the 11:00 PM- 7:00 AM shift, despite the signatures of two nurses on the narcotic count sheet verifying that the count was correct on the previous shift.
The facility's investigation into the matter lead to the removal of Staff #47 from the facility and referral to the State Board of Nursing.
Failure to maintain accountability of controlled substances was discussed with the Director of Nursing on 7/18/18 at 8:19 AM.
Refer to F607
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with facility staff, it was determined that the facility failed to administer medications with 1. an appropriate indication for use regarding Resident #88 ...
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Based on medical record review and interview with facility staff, it was determined that the facility failed to administer medications with 1. an appropriate indication for use regarding Resident #88 and 2. This was evident in 2 of 8 residents reviewed regarding unnecessary medications.
The findings include:
Review of the medical record for Resident #88 on 7/18/18 at 9:45 AM revealed active diagnosis of unspecified dementia without behavioral disturbances and delusional disorders.
Further review of the resident's physician orders revealed an order on 2/26/18 for Buspar (an anxiolytic for anxiety) 15 mg 3 times a day. Resident was noted with multiple falls and on 5/9/18 after the resident was reviewed in the facility customer at risk meeting (CAR) the medical director completed a medication review and ordered for the Buspar to be decreased to 10mg 2 times a day.
Review of the physician interim order sheet the new order was noted as Buspar GAD recommended by [medical director] CAR. Interview with the facility Director of Nursing and Corporate Nurse on 7/18/18 at 12:52 PM revealed concurrence that the GAD in the order referred to the resident's diagnosis of generalized anxiety disorder and the notation of CAR was referring to the customer at risk meeting. Review of the electronic order revealed that on 5/9/18 staff ordered Buspar 10 mg twice a day for CAD as recommended by the patient's cardiologist.
This order continued until brought to the attention of the facility DON by the survey team.
The order was reviewed by the pharmacist, physician and nursing and not questioned for the June and July monthly reviews and administered twice a day by nursing for an inappropriate indication and not questioned.
The concerns were reviewed with Administration prior to exit on 7/19/18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
2). A review of Resident #116's medication regimen orders were conducted on 7/16/18 at 12:21 PM. It revealed that the diagnosis for the use the antidepressant drug Trazadone HCL was mental health prob...
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2). A review of Resident #116's medication regimen orders were conducted on 7/16/18 at 12:21 PM. It revealed that the diagnosis for the use the antidepressant drug Trazadone HCL was mental health problem.
The Director of Nursing acknowledged surveyor's concern during an interview on 7/16/18 at 1:30 PM.
Based on medical record review and interview with facility staff, it was determined that the facility failed to 1. provide adequate indications for the usage of an antipsychotic, and 2. ensure that all medications have an acceptable clinical indication for use. This was evident for 2 of 8 residents (#79 and #116) reviewed for unnecessary medication use.
The findings include:
Review of the medical record for Resident #79 on 7/17/18 at 12:35 PM revealed diagnosis including Alzheimer's disease and major depressive disorder.
Further review revealed admission to the facility in March 2018. admission orders included Seroquel an antipsychotic for depression, Celexa an antidepressant for depression and trazadone, an antidepressant for insomnia.
A review of the resident's medical record failed to reveal an assessment by the attending and the pharmacist around the time of the resident's admission assessing the need for the resident's antipsychotics of the potential for a gradual dose reduction. In addition, no order or assessment for a psychiatric assessment related to the use of the antipsychotics was reviewed until surveyor brought the concern to the attention of the DON.
A hospital discharge summary in the resident's medical record from January 2018 noted that the resident had no anxiety, no depression and no suicidal ideation.
At the time of exit the facility was unable to provide any documentation beyond the 1/2018 assessment regarding the resident's mental status and the need for the antipsychotic.
These concerns were reviewed with the facility DON throughout the survey and again during exit on 7/19/18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and interview it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by the observation of 4 medication e...
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Based on medical record review, observation and interview it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by the observation of 4 medication errors out of 32 opportunities for error.
The findings include:
1) On 7/13/18 review of Resident #29's medical record revealed a current order, originally dated 6/27/18, for Senokot 8.6 mg give 1 tablet by mouth two times a day for bowel regimen. Review of the Medication Administration sheet revealed the medication was scheduled to be given at 9:00 AM and 9:00 PM.
On 7/13/18 at 9:30 AM surveyor observed the medication administration to Resident #29 by nurse #24. The Senokot 8.6 was not administered during this observation. On 7/13/18 at 10:30 AM the nurse was observed calling for supply of the Senokot and documented that the medication was not given: awaiting delivery.
As of 7/19/18 no documentation was provided to indicate the Senokot was administered prior to when it was next due on 7/13/18 at 9:00 PM.
2) On 7/16/18 review of Resident #25's medical record revealed a current order, in effect since 7/11/18, for Fluticasone-Salmeterol one puff inhale orally two times a day for COPD [chronic obstructive pulmonary disease]. Fluticasone-Salmeterol is a broncodilator that can prevent the symptoms of asthma and COPD. Review of the medication administration record (MAR) revealed the medication was due to be administered at 9:00 AM and 9:00 PM.
On 7/16/18 at 9:11 AM surveyor observed the medication administration to Resident #25 by nurse #25. The Fluticasone-Salmeterol was not administered during this observation. Nurse #25 reported that he inhaler was not available and that they will have to order the fluticasone.
As of 7/19/18 no documentation was provided to indicate the Fluticasone-Salmeterol was administered prior to when it was next due at on 7/16/18 at 9:00 PM.
3) On 7/16/18 review of Resident #110's medical record revealed an order, with a start date of 6/21/18, for Docusate Sodium Capsure 100 mg two times a day. Review of the MAR revealed the medication was due at 9:00 AM and 9:00 PM. Further review of the medical record revealed a separate order, also with a start date of 6/21/18, for Senna Tablet 8.6 mg two times a day for bowel regimen. Review of the MAR revealed the Senna was due to be given at 10:00 AM and 10:00 PM.
On 7/16/18 at 10:06 AM surveyor observed the medication administration to Resident #110 by nurse #25. The surveyor observed the nurse administer one Senexon-S which was a combination medication which contained Docusate sodium 50 mg and sennoside 8.6 mg in one tablet.
As of time of exit on 7/19/18 no additional documentation had been provided that an additional 50 mg of Docusate Sodium had been administered to Resident #110 on the morning of 7/16/18.
4) Further review of Resident #110's medical record revealed an order, originally written 6/22/18, for Omeprazole 20 mg every day for GERD [gastro-esophageal reflux disease] to be given 30 minutes before meal.
On 7/16/18 at 10:06 AM surveyor observed the medication administration to Resident #110 by nurse #25. The surveyor observed the nurse administer the Omeprazole during this medication pass. Breakfast had already been served to the residents prior to 10:00 AM.
On 7/16/18 at 3:10 PM surveyor reviewed the concern with the Director of Nursing regarding the Senna and inhaler not being available to be administered, the incorrect dose of Docusate Sodium administered and the omeprazole having been administered after the resident had eaten rather than half hour before as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview with staff it was determined that the facility failed to 1. ensure insulin and syringes needed for insulin administration were kept in a secure location, and 2. ensu...
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Based on observation and interview with staff it was determined that the facility failed to 1. ensure insulin and syringes needed for insulin administration were kept in a secure location, and 2. ensure medications requiring refrigeration were kept at the required temperature. These deficient practices were identified on two out of the three nursing units in the facility.
The findings include:
1) On 7/16/18 at 1:54 PM on the 3rd floor nursing station surveyor observed a plastic bucket with insulin and syringes for the administration of insulin sitting on the counter at the back of the nurse's station. The nurse's station is open and does not have a door to prevent anyone from entering the station. The only staff present at the nursing station during this observation is the unit secretary #61.
At 2:02 PM the unit nurse manager #35 is in the nursing station documenting in a log book.
At 2:04 PM the unit nurse manager has replaced the log book on the shelf above the counter where the bucket with the insulin and needles are sitting. Unit manager then left the nursing station. A resident is observed in the hall at this time near the nurse's station. No staff is at the station at this time.
At 2:08 PM unit nurse manager is in the nursing station and surveyor asked if the bucket with the insulin is normally kept on the counter. The unit manager reported that sometimes they do, sometimes they don't. She confirmed that there were insulin pens as well as insulin vials and needles in the bucket. The unit manager also confirmed that there was nothing stopping anyone from coming into the nurse's station. She then instructed a nurse to put the bucket in the locked medication room.
On 7/16/18 at 3:08 PM the Director of Nursing reported that insulin should be kept on the [locked medication] cart or in the [locked] med room. Surveyor then reviewed the observations from 1:54 PM until 2:08 PM on the 3rd floor and the interview with the unit nurse manager #35.
2) On 7/16/18 at approximately 2:30 PM observation of the second floor medication room with the unit nurse manager #21 revealed the temperature in the medication refrigerator to be 30 degrees. The unit manager reported she would address this issue. At 2:58 pm the unit manager reported she just obtained a new thermometer for the refrigerator.
On 7/17/18 at 3:23 PM observation of the second floor medication room with the unit nurse manager #21 revealed the temperature in the medication refrigerator to again be 30 degrees. The unit manager reported that it had been 38 earlier today and that she would contact maintenance. Confirmed the refrigerator contained insulin and eye drops.
Manufactures recommendations for storing insulin indicate it should be stored between 36 - 46 degrees Fahrenheit.
On 7/19/18 at 12:25 PM surveyor reviewed the concerns with the corporate nurse #13 regarding the failure to keep the insulin and insulin supplies in a secured location and the failure to keep the medication refrigerator at the proper temperature.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on medical record review and interviews with facility staff it was determined the facility failed to have an ordered laboratory test in the resident medical record. This was evident for 1 (resid...
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Based on medical record review and interviews with facility staff it was determined the facility failed to have an ordered laboratory test in the resident medical record. This was evident for 1 (resident # 14) of 3 closed records reviewed during the facility's annual Medicare/Medicaid survey.
The findings include:
A medical record review was completed on 7/18/18 for resident #14 and upon review it was noted that a verbal order was confirmed on 4/10/18 by staff #49 to obtain a Potassium level in AM, one time only for follow-up for 1 day.
An interview was conducted with the Director of Nursing (DON) on 7/18/18 at 3:25 PM and s/he brought a copy of resident #14's potassium level to the survey team. The DON stated that s/he pulled the lab from the computer and stated that it was not in the resident medical file and that the physician did not review and/or sign the labs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based upon surveyor observation and sampling of a puree test tray it was determined that the facility failed to prepare a meal in the form to meet individual needs and physician orders.
The findings ...
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Based upon surveyor observation and sampling of a puree test tray it was determined that the facility failed to prepare a meal in the form to meet individual needs and physician orders.
The findings include:
During the sampling of a test tray on 7/16/18 at 12:43 PM secondary to residential complaints regarding food palatability it was determined that during the tasting of the pureed mixed vegetables, small bits approximately 1/4 inch in length, were identified by 2 different surveyors who tested the trays, in addition to the Certified dietary manager (CDM).
When the CDM was questioned as to what was in the puree, he identified the small bits as possible pieces of skin [of vegetables].
This concern was brought to the attention of the Administrator on 7/16/18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on observation, medical record review and interview it was determined that the facility failed to maintain communication between hospice services and facility staff. This was evident for 1 resid...
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Based on observation, medical record review and interview it was determined that the facility failed to maintain communication between hospice services and facility staff. This was evident for 1 resident reviewed for hospice (#67) during the investigative portion of the survey.
The findings include:
Initial tour and observation of Resident #67's room on 7/12/18 at 10:07 AM revealed resident in bed with the tube feeding running, noted at 90 ml/hour.
Review of the resident's electronic medical record on 7/16/18 at 1:09 PM revealed an admission order to Hospice care on 7/3/18 with concurrent orders to include discontinuation of labs, weights and supplements.
Surveyor toured Resident #67's room on 7/17/18 at 9:07 AM and noted resident asleep with tube feeding infusing at 90 ml/hour.
Review on 7/17/18 at 10:07 AM of Resident #67's paper chart revealed a communication form from hospice dated 7/12/18 recommending changing the residents feeding from 90 ml/hour to 50 ml/hour to prevent aspiration.
Surveyor brought the recommendation to the attention of the Corporate nurse at 12:20 PM, and the concern that no documentation regarding acknowledgement of the recommendation could be found.
Follow up with the Corporate nurse at 5:06 PM on 7/17/18 revealed that the recommendation from hospice was missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it was determined that the facility failed to put a system in place to ensure proper infection surveillance policies and procedures were in place by 1) not e...
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Based on record review and staff interview it was determined that the facility failed to put a system in place to ensure proper infection surveillance policies and procedures were in place by 1) not ensuring that the facility's Infection Prevention and Control Policies were reviewed annually, and 2). not verifying evidence of immunity when an employee stated that they never had or been vaccinated for measles, mumps, rubella or was ever tested for evidence of immunity. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.
The findings include:
1). Review of the facility's Infection Prevention and Control Policies was conducted on 7/18/18 at 1 PM. It revealed that there was no indication that the policies were reviewed at annually.
Review of the facility's ongoing analysis of surveillance data and review data tool revealed incomplete documentation and lacked evidence that any follow-up activity was thoroughly conducted.
During an interview with the Director of Nursing on 7/18/18 at 2:44 PM she explained that due to staff vacancies, she had taken on the responsibilities of the Quality Assurance /Nurse Practice Educator role for the past year and admitted that some of the procedures have not been fully conducted.
(Cross Reference F 726)
2). Review of GNA #64's declaration of immunization record dated 04/18/18 revealed that she checked that she did not have or was immunized or tested for immunization for Measles, Mumps and Rubella (MMR).
During an interview with the Director of Nursing (DON) on 07/18/18 at 2:44 PM, surveyor asked what would be expected if discovered that a GNA did not have proof of immunity for MMR. She replied that the GNA would be required to be tested for immunity before they would be able to work. She acknowledged that the verification was not done.
The Administrator was made aware of surveyor's findings during the exit interview on 07/19/18.
(Cross Reference F 726)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it was determined that the facility failed to put a system in place to ensure that the procedures for antibiotic stewardship program were put in place. This ...
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Based on record review and staff interview it was determined that the facility failed to put a system in place to ensure that the procedures for antibiotic stewardship program were put in place. This deficiency has the potential to affect all residents in the facility.
The findings include:
Antibiotic stewardship is a coordinated program used by healthcare facilities that promote the appropriate use of antibiotics and using the right antibiotic for each infection to improve patient outcomes and decrease the spread of infections caused by multi-drug resistant organisms.
On 7/19/18 at 11:12 PM a review of the facilities antibiotic steward program was conducted. Review of the facilities line listing; a list of residents that are receiving antibiotic treatments failed to document residents' signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments are needed. Further review of the line listing revealed that the list did not contain all residents that were receiving antibiotic treatment.
In addition surveyor discovered that a resident (Resident #90) was admitted to the facilty in June and required the resident to remain alone in a separate private room because of an active infection that continued through the month of July, however the resident was not included on the June or the July line listings.
During an interview with the Director of Nursing on 7/18/18 at 2:44 PM she explained that due to staff vacancies, she had taken on the responsibilities of the Quality Assurance/Nurse Practice Education role for the past year and admitted that some of the procedures have not been fully conducted.
Cross Reference F 726
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that the facility failed to maintain an effective pest control progra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. This deficient practice has the potential to affect all residents, staff and visitors in the facility.
The findings include:
1). During the initial tour of the facility on 07/12/18 at 9:10 AM, numerous gnats were noted at the 4th floor nurse station and in room [ROOM NUMBER] by surveyor. At 9:34 am surveyor noted gnats in and outside room [ROOM NUMBER] and at 10:21 AM, gnats were noted outside of room [ROOM NUMBER].
On 7/13/18 during unit dining service observations surveyors noted multiple gnats flying around in the hallways of all units and on food trays. Surveyors had also found multiple gnats in the conference room during the day.
During an interview with the Director of Nursing and Administrator on 7/13/18 at approximately 2:00 PM the Administrator revealed that earlier in the week, a bathroom toilet had broken on 2nd floor and the leakage had also affected the main floor. It was a day or two later that staff started seeing the gnats.
The Administrator added that an exterminator was called out and was in the process of treating the building confirming surveyors' findings. However, on 7/16/18 at 10:29 AM gnats were noted by surveyor around the 4th floor's nurse station, in the conference room throughout the day and in various places in the facility daily during the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
2. On 07/12/18 at 09:42 AM an interview was conducted with Resident #317. The resident stated that he/she was anxious after finding out that a geriatric nursing assistant (GNA) that had treated her/hi...
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2. On 07/12/18 at 09:42 AM an interview was conducted with Resident #317. The resident stated that he/she was anxious after finding out that a geriatric nursing assistant (GNA) that had treated her/him roughly and disrespectfully during their first weekend at the facility had been assigned to care for them that day.
The resident stated that on the day of admission they were instructed by nursing staff to be pushed in their wheelchair around the unit as a safety precaution. The following day, on 06/30/18, Resident #317 had spent time in the unit's day room and was ready to return to his/her room. The resident's GNA (staff #31) was sitting nearby the resident and was asked to push the resident back into his/her room.
The resident watched and waited as GNA #31 conversed with another employee on the other side of the resident. Suddenly GNA #31 stood up, grabbed the wheelchair, jerked it toward the door, rushed out of the day room, down the hallway into the resident's room and walked away without speaking.
When asked if the incident was reported to anyone, the resident replied that the Social Worker (SW #3) was made aware when she visited the following day. The SW replied that she did not like to hear when these things happened and informed the resident that she would address the concern and keep the resident updated.
The resident added that later in the dayroom, the same GNA entered to ask another resident if they had eaten. After asking twice, the GNA leaned over next to resident #317, pretended to write then stated, let me email headquarters, and walked away. It wasn't until the morning of the day of the survey interview that the resident saw the GNA again when she came into their room to offer care.
During an interview on 7/12/18 at 10:45 AM, the Administrator and Director of Nursing (DON) were asked if they were currently investigating any allegations of abuse. The DON replied that she received a report of abuse from the SW about 10 minutes prior to the interview regarding Resident #317. When informed that the resident stated to the surveyor that the alleged GNA was assigned to them this morning, the DON left the conference room. She returned at 11:15 AM to state that the alleged GNA (staff #64) was interviewed and removed from the premises.
However, the DON returned on 7/12/18 at 2:20 PM, and revealed that during her interview with Resident #317 s/he visibly identified GNA (staff #31) as the accused person. She added that unlike GNA #64, this individual had worked in the facility and assigned to the resident on the date of the incident. Additionally, GNA #31 acknowledged an interaction with the resident during their interview and was removed from the premises.
(Cross Reference F 610)
Based on review of facility reported incident and investigation it was determined that the facility failed to protect residents from verbal abuse and neglect. This was found to be evident for two out of three residents (#49 and #317) reviewed for possible abuse during the investigative stage of the survey.
The findings include:
1. On 7/17/18 Resident #49's medical records were reviewed. This review revealed a Brief Interview for Mental Status a score of 13 out of 15 indicating the resident was cognitively intact.
On 7/17/18 review of a facility self-report incident revealed that on 11/7/17 the resident reported that geriatric nursing assistant (GNA) #40 had been verbally abusive and neglectful.
Further review of the facility reported incident regarding the resident that occurred on 11/7/17 revealed that staff #40 allegedly argued with Resident #49 telling the resident that if he/she did not like the way she/he was cleaned, she/he could do it her/himself and failed to provide care for the resident.
Review of the witness statements revealed that staff #41 was sitting outside of the resident's room and she heard the GNA tell the resident, 'if you don't like the way I am cleaning you, you can get a [explicative] washcloth and clean yourself.'
Further review of the witness statements revealed interview with the resident's then roommate completed by the Director of Social Services, which revealed that staff #40 would only come in at the end of the shift to change them. She reportedly never wiped them, just changed the diaper. The roommate further revealed that when he/she asked the GNA to wipe her/him, she replied why don't you do it yourself if you don't like the way I do it.
The resident's allegations were substantiated by the facility. Review of the facility final report revealed: The facts in this investigation support probable abuse and neglect. The GNA was terminated on 11/22/17.
All findings and concerns discussed with the Director of Nursing and the Administrator during the survey exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility failed to refer Staff #38 to the Board of Nursing upon substantiating an allegation of abuse.
Surveyor review of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility failed to refer Staff #38 to the Board of Nursing upon substantiating an allegation of abuse.
Surveyor review of a facility reported incident (MD00119925) on 7/18/18, revealed an allegation that on 9/22/17 Staff #38 was rude and demeaning to Resident #217. The facility report noted that Staff #38 was terminated due to a previous incident of not following facility policy. Resident #217's abuse allegation was substantiated by the facility.
Review of Staff #38's employee file revealed s/he was terminated on 9/22/17 for failure to promptly report an allegation of abuse reported by Resident #64 that occurred on 9/16/17. Other customer service issues were noted in the employee's record.
Further review of the facility's investigation documents revealed that despite substantiating the abuse alleged by Resident #217 the facility failed to refer the matter to the Board of Nursing for further review.
The findings were discussed with the Director of Nursing on 7/17/18 at 11:57 AM.
5. The facility failed to ensure that Staff #39, a contractual staff member, who allegedly verbally abused Resident #218 received annual abuse prevention education.
Surveyor review of facility reported incident #MD001237771 revealed an allegation of employee to resident abuse concerning Resident #218, which was unsubstantiated.
Surveyor review of Staff #39's employee file revealed there was no evidence s/he received annual abuse prevention training or following the alleged incident.
The findings were discussed with the Director of Nursing and Administrator on 7/19/18 at approximately 1:15 PM.
6. The facility failed to implement procedures for prompt investigation of an allegation of abuse and ensure residents remained safe.
Surveyor review of facility reported incident MD00119907, on 7/18/18, revealed an allegation that Staff #40 physically abused Resident #64 on 9/16/18 during the 3:00 PM - 11:00 PM shift.
In a written statement, Staff #38 reported an attempt to contact the Director of Nursing on 9/16/17 at approximately 10:48 PM and the Unit Manager regarding the incident. The statement did not indicate Staff #40 was removed from the area/facility pending the outcome of the investigation or that other measures to maintain resident safety were implemented. Medical record review did not indicate the physician was notified of the allegation.
Further review of the facility's investigation information revealed the Director of Nursing did not receive notification regarding the allegation of abuse until 9/17/18 at 8:39 PM.
7. The facility failed to promptly report the misappropriation of controlled substances to the Office of Health Care Quality and conduct a thorough investigation.
Surveyor review of facility reported incident #MD00120438 revealed a concern that Resident #368 failed to receive Oxycodone as prescribed by his/her physician that was signed off as given on the Medication Administration Record. The facility noted the date of this incident as 9/23/17.
Review of the facility's investigation revealed that on 9/21/17 at approximately 1:45 AM, Staff #46 contacted the Director of Nursing to report inaccuracies in the narcotics count. A Drug Diversion Reporting Form noted 1 bottle of Methadone and 3 Oxycodone tablets were missing. Staff #46 reported that Staff #47 had possession of the keys during the 3:00 PM - 11:00 PM shift and upon her/his return from break it was discovered during the narcotics count for the 11:00 PM - 7:00 AM shift that narcotics were missing.
The Office of Health Care Quality did not receive a report of the misappropriation until 9/25/18. The facility report only indicated one resident was affected (Resident #368). Further review of the facility's investigation revealed a statement from the Director of Nursing that indicated at least three residents were affected (Residents #368, #367 and #23). This was confirmed in a phone interview with the Director of Nursing on 8/1/18 at 4:25 PM.
The investigation did not include a statement from the off-going 7:00 AM-3:30 PM nurse that counted the narcotics with Staff #47 to determine if there were any irregularities noted. There was no evidence the facility reviewed the systems related to controlled medication accountability including the disposition of medications keys when staff take a break and the procedure for handing off the keys and general practices related to counting controlled substances to ensure there is no diversion.
Facility staff failed to promptly report medication diversion to the Office of Health Care Quality re-examine the systems and processes related to maintaining accountability for controlled substances and provide training/re-training regarding abuse prevention.
The findings were discussed with the Director of Nursing on 7/18/18.
3. Review of facility reported incident #MD00127092 revealed Resident #72 reported that Resident #59 came into his/her room and fondled his genitals.
A review of the facility's investigation was done on 7/17/18. Resident #72 reported this happened on the morning of 5/18/18, however, it occurred on 5/16/18. According to the investigation, on 5/16/18 geriatric nursing assistant (GNA) #1, responded to Resident #72 who was yelling out at approximately 7:30 PM, and found Resident #59 sitting in the chair in Resident #72's room. The resident reported to the Social Worker that Resident #59 came into his/her room and got under the covers with him/her and fondled his/her private parts while s/he was sleeping.
An interview was conducted with the Director of Nursing (DON) on 7/17/18 at 12:33 PM and s/he stated the following: Resident #72 has a history of exposing his/herself to staff and that the facility had documentation of this. The DON gave an account of a recent incident in which Resident #72 called and requested assistance, stating that his/her brief was wet. The DON stated that s/he was on the unit and responded to the resident room, and when s/he arrived, the resident had his/her genatalia in her/his hand shaking it. The DON stated that s/he wrote this up so that it was documented. The DON went on to explain that Resident #72 did not expose his/herself to residents, only to staff and only in his/her room.
The DON stated that GNA #1 worked for an agency and did not report that Resident #59 was found in Resident #72's room to the administrative team.The DON was asked if Resident #59 had a history of wandering and s/he responded that the resident had never wandered into this resident room. The DON went on to say that a stop sign was placed in the doorway of Resident #72's room to prevent Resident #59 from entering into the room. The DON further stated that both residents were evaluated by the physician and psychiatric services following the incident. The DON stated that abuse was unsubstantiated.
Based on review of employee files and interview with staff it was determined that the facility failed to 1. have an effective system in place to ensure criminal background checks were completed prior to allowing employees to work with residents, 2. follow the abuse policy by failing to keep residents free from abuse (#72 and #59), 3. refer Staff #38 to the Board of Nursing upon substantiating an allegation of abuse against Resident #217, 4. ensure that Staff #39 who allegedly verbally abused Resident #218 received annual abuse prevention education, 5. promptly initiate an investigation into an allegation of resident abuse (Resident #64), and 6.) promptly report the misappropriation of controlled substances for Resident's #368, #23 and #367 to the Office of Health Care Quality and conduct a thorough investigation of the incident. This was found to be evident for 9 of 13 abuse investigations completed during the investigative portion of the survey.
The findings include:
Review of the facility's Abuse Prohibition policy revealed the following: Process 2. The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attmepting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries.
1. On 7/18/18 review of geriatric nursing assistant (GNA) #19's employee file revealed the employee was hired under last name A but her GNA license was under name B.
Further review of the employee file revealed an email, dated 4/4/18, notifying the Human Resource Director (Staff #60) that he GNA #19 had listed an [NAME] name B which was the name on her GNA license but the background check information had not been ordered under that name.
Review of the criminal background check documentation revealed two checks had been completed, one on 4/8/18 and another on 4/17/18.
Review of employee timesheet data revealed that the employee started orientation on 3/28/18 and worked with residents on March 31, April 1, 2, 4, 5, 6, 9, 10, 11, 13, 14, 15, and 16, 2018.
On 7/18/18 at 11:43 AM surveyor reviewed the concern with corporate nurse #13 that there had been no initial background check under the name B, which was the name on the GNA's lisence, and that this had been identified by the facility with notification to the human resource director on 4/4/18, but the GNA was allowed to continue to work prior to the receipt of the completed background check information.
As of time of exit on 7/19/18 no additional documentation or information had been provided regarding this concern.
2. On 7/17/18 review of MD00123769 revealed an abuse allegation was made against GNA #20 in March of 2018. Interveiw with the Director of Nursing (DON) revealed that this GNA was not an employee of the facility but was an agency staff. Review of the Criminal and Offense History report revealed the search period was 2009 - 2016.
On 7/17/18 at 4:08 PM when aked why the background check only went to 2009 the DON reported she would have to check with the staffing agency. Later in the survey, in response to this question, the DON presented with a document about consumer reporting agencies that may not report negative information that is more than seven years old. On 7/18/18 at 3:51 PM Surveyor discussed the concern with the DON that the information provided was for financial issues only and failed to address the issue of criminal histories.
As of time of exit on 7/19/18 no additional documentation or information had been provided regarding this concern.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7) On 7/12/18 at 9:42 AM an interview was conducted with Resident #317. The resident stated that they were anxious after finding...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7) On 7/12/18 at 9:42 AM an interview was conducted with Resident #317. The resident stated that they were anxious after finding out that a GNA that had treated them roughly and disrespectfully during their first weekend at the facility had been assigned to care for them that day.
When asked if they had reported the incident to anyone the resident replied that the Social Worker (SW; staff #3) was made aware when she visited them the following day. The SW stated that the facility would investigate the incident and would update the resident. However, after not hearing from the SW for several days, the resident shared the incident with the Activity Director (AD; staff #4) who then bought SW #3 in to speak with the resident.
The resident went on to say that s/he told SW #3 that it had been close to 2 weeks and no one had gotten back to them regarding the incident. The SW replied to the resident, We don't tell the clients what we do.
During an interview on 7/12/18 at 10:45 AM, the Administrator and Director of Nursing (DON) were asked if they were currently investigating any allegations of abuse. The DON replied that she received a report of abuse from SW #3 about 10 minutes prior to the interview regarding Resident #317. When informed that the resident stated to the surveyor that the alleged GNA was assigned to them this morning, the DON left the conference room. She returned at 11:15 AM to state that after review of the day's staff assignment schedule for Resident #317, GNA #64 was identified, interviewed, and removed from the premises.
However, the DON returned on 7/12/18 at 2:20 PM, and revealed that during her interview with Resident #317 s/he visible identified GNA #31 as the accused person. She added that unlike GNA #64 this individual had worked in the facility and assigned to the resident on the date of the incident. Additionally the GNA #31 acknowledged an interaction with the resident during their interview and was removed from the premises.
Interview with SW #3 on 7/12/18 at 11:29 AM was conducted with survey team. The SW denied speaking with Resident #317 that Sunday and stated that she did not work weekends.
She did however admit that on 7/11/18 she and the AD #4 met with the resident. It was during this meeting that s/he accused a GNA of being rough with them along with several other concerns which were documented and submitted to the DON the following morning.
When asked if she thought the interaction between the resident and the GNA as described to her was considered abuse, the SW replied she did not until now.
Review of the monthly schedule for the facility's weekend manager coverage revealed that SW #3 had worked the Sunday of the reported incident. In addition, during an interview with AD #4 on 7/12/18 at 2:30 PM, she corresponded the resident's account that SW #4 was notified of the incident on that day.
During that interview, surveyor asked AD #4 what the normal process is when she received a grievance concern from a resident. The AD replied that on the same day she would fill out a grievance and concern form and give it to appropriate department that needed to address it. She also stated that it was expected that the process would take 72 hours. She went on to say that if it was something like an abuse, that she would report it right away.
Surveyor asked the AD if she considered anything that Resident #317 told her that day as abuse. The AD replied the description of the staff's roughness towards the resident. She added that the resident did not want her to say anything about it. She went on to say that if the resident was frail, she would have reported the incident but since s/he appeared to be okay and replied that s/he was okay she did not pursue the matter. She also shared that although she would consider the incident as an abuse, she did not think it was at level (of severity) to report it immediately. The Administrator the DON and SW #3 were present during the interview and acknowledged surveyor concerns.
A follow up interview with the SW #3 in the presence of the Administrator and DON was conducted on 07/12/18 at 2:45 PM. During the interview the SW admitted having several conversations with Resident #317 since their admission however it wasn't until the Activity Director invited her to meet with the resident on 7/11/18 that an allegation of abuse was shared with her.
The Administrator and DON acknowledged that staff failed to recognize and timely act upon Resident #317's allegation of abuse. This resulted in a delay in the investigation and allowed the accused GNA to work another shift with the resident.
(Cross Reference F 600)
4) Facility staff failed to ensure a thorough investigation of allegations that Resident #89 was handled roughly by Staff #42.
Medical record review revealed Resident #89 was admitted to the facility with diagnoses that included but were not limited to Paraplegia (paraplegia is an impairment in motor or sensory function of the lower extremities) and Neurogenic Bowel and Bladder.
Neurogenic bowel is a condition that causes loss of bowel function after a spinal cord injury (SCI). Neurogenic bladder dysfunction, sometimes simply referred to as neurogenic bladder, is a dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves that control urination.
The medical record contained a care plan, with an initiation date of 6/8/18, that addressed the resident's risk for decreased ability to perform Activities of Daily Living related to paraplegia.
Review of Resident #89's admission MDS assessment dated [DATE] revealed the facility staff coded the resident in Section G Functional Status G0110 ADL Assistance: Bed Mobility as a 3/1 (requires the extensive assistance of 1 staff). Facility staff entered a BIMS score of 15/15 in section C Cognitive Patterns.
On 6/30/18 resident #89 reported that Staff #42 swung his/her leg over during incontinence care causing right hip pain. The physician ordered an x-ray of the right hip which was negative for a fracture. Staff #42 was an agency staff who was placed on administrative leave during the investigation after which it was determined s/he could return to the facility but would not care for Resident #89.
During an interview with the surveyor on 7/17/18 at 2:05 PM the resident stated Staff #42 threw his/her leg over to provide incontinence care and he/she screamed in pain. The resident stated s/he felt pain in his/her back as well. The resident further stated it was the manner in which Staff #42 treated him/her, which s/he described as very harsh, that was so upsetting.
Further medical and administrative record review failed to reveal evidence that the facility reassessed positioning techniques, the need for a rehabilitation screen to evaluate positioning, the number of staff needed to provide care to the resident and the need for re-education of staff regarding positioning during care. There was no indication that the ADL care plan was reviewed or revised to ensure interventions were individualized to meet the resident's needs.
The findings were discussed with the Director of Nursing on 7/18/18 at 4:55 PM.
5) The facility failed to conduct a thorough investigation into the potential misappropriation of narcotics for Resident #62.
Medical record review revealed Resident #62 was admitted to the facility with diagnoses that included but were not limited Neuropathy, Scoliosis, Congenital Hip Dysplasia, Spinal Cord Compression and Sacral Pressure Ulcer. Review of the May 2018 Medication Administration revealed the resident was receiving Morphine Sulfate daily for chronic pain.
Surveyor review of facility reported incident #MD00127006 on 7/17/18 revealed a concern that on 5/22/18 Resident #62's Morphine was not available.
According to the facility's investigation, Staff #43 signed a receipt for 30 Morphine Sulfate tablets on 5/19/18. A Pharmacy Shipment Slip noted 30 tabs of Morphine Sulfate were sent to the facility for Resident #62 on 5/21/18 at 1:46 AM and was signed for by Staff #43 on 5/21/18 at 1:46 AM.
In a written statement Staff #44 reported that on 5/22/18 during medication pass, the resident's Morphine was not available and it was necessary to get the medication from the emergency stock. The medical record also contained a Controlled Substance Prescription form, dated 5/22/18, that requested the pharmacy to dispense 60 tablets of Morphine Sulfate for Resident #62.
Medical record review revealed a Medication Progress note dated 5/22/18 at 1:37 PM that reported Morphine Sulfate for chronic pain was not available. A Medication Progress note dated 5/22/18 at 11:21 PM also noted the medication was not available.
An agency interview form, dated 6/14/18 at 1:00 PM, noted that Staff #43 explained that there was a miscommunication. It was further noted that Staff #43 called the pharmacy and investigated the matter of the alleged missing Morphine herself/himself and reported his/her conclusion to the Director of Nursing. The form noted that Staff #43 could return to duty and was aware that failure to meet the expectations for the job may result in a performance action plan. The investigation packet did not contain a statement from Staff #43.
Further review of the facility's investigation material failed to reveal confirmation of the miscommunication noted by Staff #43, documentation from the pharmacy confirming that the Morphine was not delivered to the facility and signed for by Staff #43 or validation that Staff #43 received education regarding the process for receiving and accounting for controlled substances.
During an interview with the surveyor, on 7/18/18 at 8:19 AM, the Director of Nursing (DON)stated the pharmacy discovered that Staff #43 signed for Tramadol, not Morphine on 5/19/18. The DON further stated education was provided to Staff #43 regarding receipt of narcotics.
Although the facility did not validate misappropriation of resident#62's medication they failed to collect all of the necessary information needed to support the conclusion.
6) The facility failed to conduct a thorough investigation of a fracture of unknown origin sustained by Resident #21.
Medical record review revealed Resident #21 was admitted to the facility with diagnoses that included but were not limited to Dementia, Left Leg Fracture, Muscle Weakness, Compression Fracture of the Thoracic Vertebrae, non-traumatic and Malnutrition.
The medical record contained a care plan, with an initiation date of 10/28/17, that addressed the risk for decreased ability to perform ADL's related to falls, muscle weakness and fatigue. The interventions included monitoring medications for side effects, monitor the resident for complications of immobility and quarter side rails to be used as an enabler, all with an initiation date of 11/1/17.
Review of the Quarterly MDS assessment dated [DATE] revealed the facility staff entered a BIMS score of 13 out of 15 in Section C Cognitive Patterns and on 4/23/18 a score of 5/15 was entered in the assessment. Facility staff coded the resident in section G Functional Status G0110 A Bed Mobility and B Transfers as a 3/3 (extensive assistance - 2-person physical assist).
Review of facility reported incident #MD00121634, on 7/16/18, revealed Resident #21 complained of left hip pain on 1/4/18 and 1/5/18. An x-ray of the hip done on 1/5/18 confirmed the resident had a fracture. The resident made several allegations of rough handling as an explanation for the injury. The resident alleged s/he was thrown in her/his wheelchair by a male and female staff.
A progress note, written by Staff #45, dated 1/4/18, reported the resident was evaluated for a complaint of hip pain and reported being pushed by another resident, which resulted in a fall. It was also noted that the resident was refusing to get out of bed.
During an interview with the surveyor, on 7/19/18 at 11:10 AM, Resident #21 denied falling and was unable to give information regarding how the injury was sustained.
The facility's investigation concluded the resident was not abused and did not suffer trauma, however there was no evidence the facility re-assessed positioning and transfer methods, and level of supervision to ensure care was being provided safely.
The findings were discussed with the Director of Nursing on 7/18/18 at 4:55 PM.
3) Review of facility reported incident #MD00127092 alleged that Resident #59 entered Resident #72's room at approximately 5:00 AM on 5/18/18 and got into his/her bed and fondled him/her while they were asleep.
An interview was conducted with the Director of Nursing (DON) on 7/17/18 at 12:33 PM and s/he stated that Resident #59 wandered into Resident #72's room in the early morning hours. The DON went on to say that geriatric nursing assistant (GNA) #1 who worked and responded to Resident #72's room found Resident #59 sitting on the chair in the room. The DON stated that GNA#1 took Resident #59 back to his/her room. The DON further stated that GNA #1 is an agency employee and did not report this incident to the supervisor. The DON confirmed that the facility did not conduct an investigation until 2 days later because GNA #1 did not report Resident #72's concerns to the supervisor and or administration. Abuse was unsubstantiated.
Based on interviews of residents and facility staff, review of medical records and other pertinent documentation it was determined that the facility failed to thoroughly investigate 1. allegations of missing money (Resident #12 and #2), 2. allegations of abuse and report this to the proper authorities in a timely manner (Residents #72 and #59), 3. an allegation of abuse by a functionally impaired resident (Resident #89) who complained of right hip pain after receiving care, 4. the potential misappropriation of narcotics for Resident #62, 5. a fracture of unknown origin sustained by a cognitively and functionally impaired resident (Resident #21), and failed to take appropriate action in response to a resident's allegation of abuse which delayed an investigation and permitted the caregiver to work another shift with the resident (Resident #317). This was evident for 8 of 59 residents reviewed during this survey
The findings include:
The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment directs the facility staff on issues that may need to be addressed.
Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.
1) Review of a facility reported incident revealed that on the morning of 5/29/18 Resident #12 noticed that $50 was missing and requested a geriatric nursing assistant help to look for the money. Review of the investigation revealed that several staff were interviewed. However, nurse #37, who was assigned to the resident for the night shift of 5/28 [which ended on the morning of 5/29], was not interviewed nor provided a statement.
On 7/19/18 at 12:25 PM surveyor reviewed the concern with the corporate nurse #13 regarding the failure to complete a thorough investigation as evidenced by failure to interview the nurse who had been assigned to work with the resident the shift prior to the discovery of the missing money. As of time of exit at 3:00 PM no additional documentation had been provided regarding the lack of interview or statement from nurse #37.
2) On 7/13/18 Resident #2 reported to surveyor that some clothes and some money had been stolen and that this had been reported to the social worker. The resident went on to state that after the report a staff person had given him $10 and a pair of pants that were the wrong size.
Review of the facility report regarding this incident revealed the following: [Resident #2] reports that someone stole [his/her] clothes and $20.00 from [him/her] .Clothes were sent to laundry to be washed and money was located in pocket of dirty clothes. Clothes were returned to resident after washed. Misappropriation unsubstantiated.
Review of the Grievance/Concern Form, dated 7/1/18, revealed that the resident informed the social worker #3 about some missing clothes and missing $20.00 that was left in the shirt pocket.
On 7/17/18 at 1:56 PM, Social Worker #3 reported that the clothes were found but not the money.
On 7/17/18 at 2:01 PM the Director of Nursing (DON) reported that she had been told that the activity worker had gone to the laundry, found the money and returned it to the resident. Surveyor informed the DON that no statement from the activity worker was found in the investigation documentation.
On 7/18/18 at 3:22 PM, the activity worker (staff #33) reported that the resident had informed her of the missing clothes and $20.00 while she was conducting the activity assessment. The activity worker went on to report that the resident also reported missing eye glasses. The activity worker reported that she went to the laundry and a $10 bill was found. The resident informed her he had lost two $10 bills so she gave him the $10 bill that was found in the laundry. The activity worker went on to report that when she gave the resident the $10 bill the resident stated that s/he would of preferred to have gotten the glasses over the money. Activity worker confirmed that the resident never got the glasses back.
On 7/19/18 at 10:28 AM surveyor reviewed with the DON the concern regarding failure to conduct a thorough investigation regarding the missing money and the failure of staff to report the missing glasses. The DON acknowledged the concern and reported that she had been under the impression that all of the money had been returned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based on medical record review and interview with facility staff, it was determined that representatives from different departments failed to assess and code residents accurately regarding 1. presence...
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Based on medical record review and interview with facility staff, it was determined that representatives from different departments failed to assess and code residents accurately regarding 1. presence/absence of a restraint, (#48), 2. weight loss (#78), 3. a significant weight loss and the presence of a tube feeding (#95), and 4. the presence of an active major infection (#95). This was evident for 4 of 59 residents reviewed during the investigative portion of the survey.
The findings include:
The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD).
The care plan is intended to reflect resident needs and wants, along with actions and timelines to address them.
1. Review of the medical record for Resident #48 on 7/12/18 at 1:26 PM during the initial record review revealed that according to the residents most recent MDS documented on 5/20/18, the resident was coded as having a trunk restraint in place less than daily. Observations of Resident #48 during interview on 7/12/18 and again on 7/13/18 did not reveal a trunk restraint in place.
Interview with the facility Director of Nursing and MDS coordinator on 7/17/18 at 7:57 AM regarding the findings in the MDS section 'P' restraints, revealed that it was a coding error and Resident #48 did not have a restraint.
2. Observation of Resident #78 in his/her room on 7/12/18 revealed the presence of a feeding pump. Surveyor attempted to talk to the resident and secondary to a diagnosis of aphasia (difficulty in speaking), s/he gave a thumbs up and mouthed that all was 'okay.'
During the initial review of the residents medical record including a review of the residents most recent MDS completed on 6/11/18, it was noted that the resident was coded in section 'K' on as having a significant weight loss of more than 5%.
Review of the physician notes on 7/16/18 at 7:56 AM revealed a physician note on 7/6/18 stating that the resident had a significant weight loss, however, further noted no change in plan.
Interview with the Dietitian on 7/17/18 at 11:46 AM regarding her coding of the significant weight loss in section 'K,' she stated that since the documented weights showed a weight loss she had to code it that way. She did not verify the accuracy because the MDS was due, including requesting a re-weight.
Review of the documented computer weights revealed the following weights: 5/8/18-148.6, 6/3/18- 135.8; a 12.8 lb/8.6% weight loss in less than 1 month.
Review revealed that there was no reweigh, follow-up or review of the resident regarding the supposed significant weight loss that was coded in the MDS. Additionally, it was noted that the last dietitian note was completed on 3/14/18 and as of 7/18/18 there still had been no documented follow up provided to the survey team.
Interview with the MDS coordinator on 7/19/18 at 8:00 AM regarding the concerns with the documentation in section 'K' and the lack of verifying the residents weights before coding a significant weight loss, she stated concurrence that information should be verified prior to being entered into the MDS.
3. Review of the medical record for Resident #95 during the initial record review revealed that the resident was coded as having a significant weight loss and had a feeding tube.
During observation and attempted interview of the resident on 7/12/18 and again on 7/13/18 there were no signs of the resident receiving a feeding tube including equipment needed for that task.
Review of the residents medical record on 7/13/18 at 11:00 AM revealed there were no weights documented on the resident since 5/8/18, secondary to refusals.
The residents most recent MDS was completed on 6/10/18. That MDS for section 'K' coded the resident as having a significant weight loss, coding the resident as having a current weight of 136, and also having the presence of a feeding tube.
Interview with the Dietitian on 7/17/18 at 11:52 AM revealed that she was made aware on 7/16/18 of the surveyors concerns and after her own review, revealed that she had reviewed another residents information for that resident and had contacted the MDS coordinator to do a modification.
The Director of Nursing was interviewed on 7/17/18 and notified again of the concerns and she ordered a re-weight of Resident #95.
4. Further review of the medical record for Resident #95 during the initial investigation, noted that the resident was coded on the his/her last MDS for 6/10/18 as having a major infection.
The MDS coordinator was interviewed on 7/16/18 at 12:30 PM. Review of the residents medical history and diagnosis with the MDS coordinator revealed that the resident had a historical diagnosis of viral hepatitis. After further review it was determined that this was not an active infection and the resident was not currently receiving treatment for this diagnosis.
The MDS Coordinator was notified of the findings and stated that she will do a modification.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed resident #10 was admitted to the facility with diagnoses that included but were not limited to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed resident #10 was admitted to the facility with diagnoses that included but were not limited to Schizoaffective Disorder, Diabetes and other chronic health conditions requiring ongoing treatment. The medical record contained two Physician Certifications Related to Medical Condition, Decision Making and Treatment Limitations dated 2/17/16 and 2/18/16 that indicated the resident lacked adequate decision-making capacity due to Dementia.
Surveyor review of a facility reported incident, on 7/16/18, revealed that on 9/5/17 Resident #10, while on appointment with an escort, left the physician's office and was later found at a local food market.
Medical record review revealed a care plan, with an initiation date of 12/31/15, that addressed the risk for elopement. On 4/22/16 an intervention was added to utilize and monitor a security bracelet. An Elopement assessment dated [DATE] noted the resident had a history of elopement and wandering.
Further review of the medical record revealed the facility failed to update the care plan that addressed elopement until 1/5/18, four months after the resident eloped from an appointment.
The findings were discussed with the Director of Nursing on 7/18/18 at 4:55 PM.
Refer to F689
Based on medical record review and interviews it was determined that the facility failed to 1. ensure that residents received notification of care plan meetings, 2. to update a care plan to address a resident's vision needs, and 3. revise the care plan that addressed the risk for elopement for Resident #10, based on a comprehensive assessment, and reflected the individualized needs, strengths and preferences of the resident. This was found to be evident for 3 of 59 residents (Resident #33, #91 and #10) reviewed during the investigative portion of the survey.
The findings include
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
1) On 7/13/18 review of Resident #33's medical record revealed that the resident was legally blind. Review of a 5/4/18 Minimum Data Set assessment revealed a Brief Interview of Mental Status (BIMS) score of 15/15 which indicates the resident is cognitively intact. At approximately 12:30 PM during an interview, the resident denied any knowledge of having had or being invited to a care plan meeting.
Review of the medical record revealed that a care plan meeting occurred on 5/31/18. Review of the Care Plan Meeting note, dated 5/31/18 revealed the following: Family/Resident in attendance (Yes/No, who): No reply to invite. This note had been written by social worker #9.
On 7/18/18 at 2:37 PM social worker #9 reported that she provides an invitation to residents about a month before the scheduled meeting and that for visually impaired residents she also extended an oral invitation. For involved family members an invitation is mailed out, although she does not keep a copy of this letter she keeps list of when the invitation are sent out.
Review of the Care Plan Reviews Due Report that the SW provided revealed a Target Completion Date of 5/28/18 for 10 residents. The SW reported that 5/28 was a holiday so the meetings were moved to another date. When asked if the letters/notification sent out had the 5/28 date for the meetings the SW responded: probably so. There was a notation on this list that Resident #33 and a family member had been provided the notification letter and that they were sent out on 4/18/18.
Further review of the medical record failed to reveal any documentation that the resident was verbally invited to the care plan meeting.
On 7/18/18 surveyor reviewed the concern with the SW that the resident had reported no knowledge of a care plan meeting. As of time of exit on 7/19/18 no additional documentation had been provided by the SW regarding invitation to the care plan meeting.
On 7/19/18 at 12:25 PM surveyor reviewed with corporate nurse #13 the concern that the resident was not verbally notified of the care plan meeting and that several residents/family were provided the wrong care plan meeting date.
Further review of the medical record revealed that on 6/15/18 the social worker #3 wrote the follow note: .[s/e] did however, relate that he would like the blinds in his room be down and closed so that the sun does not shine directly on him .SW made Nurse manager aware of this and also lowered and closed [her/his] blinds during visit.
Observations made on 7/12, 7/13 and 7/17 revealed the resident's blinds to be up and light shining into the room. Resident's bed was located next to the window.
On 7/17/18 the resident confirmed that the light in the room bothers him/her.
Review of the resident's care plan failed to reveal any interventions in regard to keeping the blinds lowered or closed in the resident's room.
On 7/17/18 at 5:31 PM surveyor reviewed with the Director of Nursing the concern regarding failure to update the resident's care plan regarding the blinds in his room; reviewed social worker's note, resident report and surveyor observation.
2) On 7/12/18 review Resident #91's medical record revealed an order dated 1/3/18 for the following: Physical therapy Clarification order: Patient is being d/c [discharged ] from skilled PT services to continue with FMP under nursing care. FMP [functional maintenance program] and caregiver education completed at this time. Further review of the medical record failed to reveal any documentation regarding the FMP or it's implementation. At 10:46 AM surveyor requested documentation from Unit manager #35 in regard to FMP for this resident since no information could be found in the hard chart or the EHR [electronic health record. A copy of the Safe Transitions Goals/ Function Maintenance Plan was later provided by the unit manager. Review of this plan, dated 12/29/17, revealed documentation that 5 staff had been trained. The FMP included a Walking Program: Walk resident 100 feet bid [two times a day] using gait belt and wheeled walker.
On 7/16/18 further review of the medical record failed to reveal any documentation that the FMP walking program had ever been implemented for this resident. No documentation was found in review of the care plan about the FMP.
On 7/16/18 at 3:19 PM the Administrator reported that there was no formal restorative program at present, but they do train the staff. The Director of Nursing (DON) was not sure if the FMP were documented but stated that it might be in tasks. Tasks is the section of the electronic health record where the Geriatric Nursing Assistants document.
On 7/17/18 at 12:05 PM GNA #34 reported that sometimes the FMPs are put in the POC. POC is where the GNAs put their documentation of Tasks into the electronic health record.
On 7/18/18 at 11:20 AM the therapy director #7 reported that prior to the last day of therapy they start the FMP and educate as many GNAs as possible and the the unit manger if possible and a copy goes to the unit manager. She confirmed that the FMP should be put in the care plan but thought that nursing put it in. Therapy director also reported FMP included walking with the resident 100 feet BID with wheeled walker; and stated most likely the resident could do this upon discharge.
On 7/18/18 at 12:35 PM, unit nurse manager #35 confirmed that the resident had been walking prior to a change in condition in March, stating that the spouse would come in and walk with the resident. The unit manager went on to report that she thought therapy puts the FMPs into the care plans. Surveyor then reviewed the concern that there was no evidence that the FMP was ever added to the Care Plan or the Tasks section of the POC and that therapy had reported they do not add the FMP to the care plans. The Unit Manager then confirmed that the care plan had not been updated to reflect the FMP that had been established in January.
On 7/19/18 at 12:25 PM the surveyor reviewed the concern with corporate nurse #13 of the failure to implement the FMP in January and the failure to update the care plan at that time to reflect the FMP. The corporate nurse reported that no order had been written for the FMP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
3. A medical record review was completed for resident #117 on 7/17/18 at 4:45 PM and upon review it was noted that the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was not comple...
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3. A medical record review was completed for resident #117 on 7/17/18 at 4:45 PM and upon review it was noted that the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was not completed for the resident indicating the resident resuscitation status.
An interview was conducted with the Director of Nursing (DON) on 7/17/18 at 5:10 PM and s/he was made aware and stated that the facility would complete the document immediately. The DON confirmed that the resident MOLST status was complete in the computer.
Based on medical record review and interview with facility staff, it was determined that the facility failed to 1. consistently document a resident's current medications in the resident's physician summary regarding Resident #67, 2. accurately document the absence of any pressure ulcers regarding Resident #79, 3. complete a MOLST, and complete and accurate documentation of a resident's resuscitation status (#117). This was evident for 3 of 59 residents reviewed during the facility's annual Medicare/Medicaid survey.
The findings include:
1a. Review of the medical record for Resident #67 revealed a physician note completed on 6/27/18, 7/2/18, 7/6/18 and 7/14/18 all documenting that the resident was to have his/her Lantus (injection for the treatment of diabetes) discontinued secondary to low finger stick blood glucose (FSBG) requiring treatment and now continues metformin (oral pill for the treatment of diabetes). Review of the resident's medication administration record for June and July revealed the residents (FSBG) results were 1. 98-336 in June and 2. the resident was never ordered metformin although the physician referred to the resident as receiving it.
1b. Review of the physician note completed on 7/6/18 regarding Resident #67 revealed documentation that the resident has a history of hypertension (high blood pressure) that is controlled, and his/her blood pressure is trending 110-118/70's, management with Lopressor and Norvasc. The resident's medications were documented, including Metoprolol at 12.5 mg twice a day.
Further review of the resident's medical record revealed a visit by the facility CRNP on 7/5/18 who completed an assessment of Resident #67 and documented that the resident's hypertension was currently not controlled with blood pressure trending 180's/80-90. The CRNP manually took the blood pressure of Resident #67 with result of 184/86.
A new order to increase the residents Metoprolol from 12.5 mg to 25 mg twice a day was made.
The concerns regarding the attending physician's documentation of medications in the progress notes versus what the resident was receiving was discussed with the DON on 7/19/18 at 10:20 AM, throughout the survey process and again on exit from the facility on 7/19/18.
2. Review of the attending physician notes for Resident #79 on 7/18/18 revealed a note completed on 5/4/18 with a physical exam documenting 'no open areas,' however, under diagnosis an assessment an ICD code was entered for: Sacral decubitus ulcer.
Further review of the resident's record including the MDS, failed to reveal any documentation of any skin wounds or pressure ulcers.
This concern was reviewed with the DON on 7/18/18 at 8:36 AM, she concurred the resident had no previous or existing wounds at the time of the 5/4/18 physician assessment.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 5 life-threatening violation(s), Special Focus Facility, 3 harm violation(s), $306,550 in fines, Payment denial on record. Review inspection reports carefully.
- • 138 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $306,550 in fines. Extremely high, among the most fined facilities in Maryland. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Carroll Park Healthcare's CMS Rating?
CARROLL PARK HEALTHCARE does not currently have a CMS star rating on record.
How is Carroll Park Healthcare Staffed?
Staff turnover is 53%, compared to the Maryland average of 46%. RN turnover specifically is 68%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Carroll Park Healthcare?
State health inspectors documented 138 deficiencies at CARROLL PARK HEALTHCARE during 2018 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 129 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Carroll Park Healthcare?
CARROLL PARK HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ENGAGE HEALTHCARE, a chain that manages multiple nursing homes. With 140 certified beds and approximately 84 residents (about 60% occupancy), it is a mid-sized facility located in BALTIMORE, Maryland.
How Does Carroll Park Healthcare Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, CARROLL PARK HEALTHCARE's staff turnover (53%) is near the state average of 46%.
What Should Families Ask When Visiting Carroll Park Healthcare?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Carroll Park Healthcare Safe?
Based on CMS inspection data, CARROLL PARK HEALTHCARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Maryland. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Carroll Park Healthcare Stick Around?
CARROLL PARK HEALTHCARE has a staff turnover rate of 53%, which is 7 percentage points above the Maryland average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Carroll Park Healthcare Ever Fined?
CARROLL PARK HEALTHCARE has been fined $306,550 across 1 penalty action. This is 8.5x the Maryland average of $36,144. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Carroll Park Healthcare on Any Federal Watch List?
CARROLL PARK HEALTHCARE is currently on the Special Focus Facility (SFF) watch list. This federal program identifies the roughly 1% of nursing homes nationally with the most serious and persistent quality problems. SFF facilities receive inspections roughly twice as often as typical nursing homes. Factors in this facility's record include 5 Immediate Jeopardy findings, a substantiated abuse finding, and $306,550 in federal fines. Facilities that fail to improve face escalating consequences, potentially including termination from Medicare and Medicaid. Families considering this facility should ask for documentation of recent improvements and what specific changes have been made since the designation.