RIDGE CREST NURSING CENTER
For profit - Corporation
120 Beds
CIRCLE B ENTERPRISES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
18/100
#445 of 479 in MO
Last Inspection: November 2023
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Ridge Crest Nursing Center has received a Trust Grade of F, which indicates significant concerns and a poor overall performance. It ranks #445 out of 479 facilities in Missouri, placing it in the bottom half of all nursing homes in the state, and it is the lowest-ranked of the five facilities in Johnson County. The facility's performance has remained stable over recent years, with 50 deficiencies reported, including a critical incident where a resident suffered a serious neck injury due to inadequate fall prevention measures. While the staffing turnover is impressively low at 0%, there is less RN coverage than 85% of Missouri facilities, which raises concerns about the quality of oversight for residents' care. Additionally, there have been no fines recorded, but the overall care quality is rated poorly, with numerous incidents of care failures, including delays in wound treatment and a lack of appropriate fall interventions. Families should weigh these significant weaknesses against the few strengths before making a decision.
- Trust Score
- F
- In Missouri
- #445/479
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Missouri facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
18/100
Bottom 8%
Review needed
2 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Chain: CIRCLE B ENTERPRISES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 50 deficiencies on record
1 life-threatening 2 actual harm
Feb 2025
1 deficiency
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who required staff assistance with b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who required staff assistance with bathing received baths and/or showers to meet the needs of four sampled residents (Resident #1, Resident #3, Resident #4, and Resident #6) out of six sampled residents. The facility census was 50 residents.
The facility was asked for the Bathing/Shower Policy and was provided with a copy of Code of State Regulations 19 CSR 30-85 (67 - 95).
-The Administrator said the facility goes by the standard of care, generally two baths per week minimum, unless refused or care plan requests for one bath per week.
1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Glaucoma (a group of eye conditions that can cause blindness).
-Legal blindness (a significant level of vision impairment).
Review of the resident's Care Plan dated 2/1/25 showed the resident did not have a Care Plan for Activities of Daily Living (ADLs) for the resident's cares.
Review of the resident's entry Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/22/25 showed only the resident's identification information.
Review of the resident's paper bath sheets from 1/22/25 to 2/9/25 showed no paper bath sheets were available for review on 2/10/25.
Review of the resident's Electronic Medical Record (EMR) on 2/10/25 showed:
-Baths for the previous 30 days were provided to the resident on 1/27/25.
-Staff documented Not Applicable on 1/31/25 and 2/7/25.
Observation and interview on 2/10/25 at 1:16 P.M., showed:
-The resident said he/she had only one shower since he/she was admitted to the facility on [DATE].
-He/She had asked the staff for showers, but staff said they did not have the time and were shorthanded.
-He/She wants a shower at least twice a week.
-He/She had body odor and his/her hair was greasy and uncombed.
2. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:
-Hemiplegia (paralysis on one side of the body) and Hemiparesis (muscle weakness on one side of the body) following cerebral infraction (stroke) affecting right dominant side.
-Legal blindness.
Review of the resident's undated Care Plan showed the resident required moderate assistance from staff for bathing.
Review of the resident quarterly MDS dated [DATE] showed the resident:
-Was moderately cognitively impaired.
-Required substantial/maximum assistance by staff for bathing.
Review of the resident's EMR on 2/10/25 showed baths for the previous 30 days were provided to the resident twice on 1/28/25, 1/29/25, 2/1/25, and 2/8/25.
Review of the resident's paper bath sheets for the previous 30 days showed baths were offered and/or received:
-The resident received two baths from 1/10/25 - 1/28/25.
-The resident received one bath from 1/29/25 - 2/9/25.
During an interview on 2/10/25 at 1:31 P.M., showed:
-The resident had requested showers at least once a week but was not getting them.
-He/She went about a month without a shower before finally getting one at the end of January.
-He/She requires staff to help him/her with the bath/shower.
-He/She does not care what day or time he/she just wants a bath/shower.
-He/She feels dirty, and it upsets him/her when no showers are given.
-He/She was given a shower on 2/8/25.
3. Review of Resident #4's admission Record showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of Hemiplegia (a medical condition that causes paralysis or weakness on one side of the body) and Hemiparesis following a cerebral infraction affecting his/her left non-dominant side.
Review of the resident's undated Care Plan showed the resident required max assistance of two staff with showering twice weekly and as necessary.
Review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was moderately cognitively impaired.
-Was totally dependent on staff for bathing.
Review of the resident's EMR on 2/10/25 showed baths for the previous 30 days were provided to the resident on 1/17/25 and 1/30/25. Staff documented not applicable on 1/14/25, 1/21/25, and 2/4/25.
Review of the resident's paper bath sheets from 1/10/25 to 2/9/25 showed no paper bath sheets were provided on 2/10/25.
Observation and interview on 2/10/25 at 2:01 P.M., showed:
-The resident did not answer any questions.
-He/She just sat in his/her wheelchair and looked down at the floor.
-He/She had body odor and his/her hair was greasy.
4. Review of Resident #6's admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning that interferes with daily life and activities).
Review of the resident's undated Care Plan showed the resident:
-Provide sponge bath when a full bath or shower cannot be tolerated.
-The resident requires partial/moderate assistance by one staff with showering twice a week in the afternoon and as necessary.
Review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Required substantial/maximal assistance by staff for bathing.
Review of the resident's EMR on 2/10/25 showed baths for the previous 30 days were provided to the resident on 1/15/25, 1/19/25, and 1/26/25. Staff documented not applicable on 1/12/25.
Review of the resident's paper bath sheets from 1/10/25 to 2/9/25 showed no paper bath sheets were provided on 2/10/25.
Observation and interview on 2/10/25 at 2:15 P.M., showed:
-The resident was not interview able due to being severely cognitively impaired.
-His/her hair was greasy.
5. During an interview on 2/10/25 at 2:29 P.M., Certified Nursing Assistant (CNA) A said:
-They have a bath aide to give the residents their baths/showers when he/she had the time.
-No baths/showers are given on the days the bath aide was off because there was not enough staff to give them.
-Resident should get two baths/showers a week and as needed.
-Each bath/shower should be documented in the resident's chart.
During an interview on 2/10/25 at 2:46 P.M., Licensed Practical Nurse (LPN) A said:
-Residents are to be offered two baths/showers a week.
-They do not have enough staff to give two baths/showers a week.
-They do have a bath aide that works 12-hour days for three days then off two days.
-The bath aide gets pulled to work the floor as a CNA and is not able to give all of the residents scheduled that day a bath/shower.
-No baths/showers are given on the bath aides days off.
-The CNAs were expected to give the residents on the hall that they were working on a shower if due, but they do not have enough help to do that.
-A shower sheet was to be filled out anytime a resident was given a bath/shower or refuses a bath/shower.
During an interview on 2/10/25 at 3:41 P.M., the Administrator said:
-The bath/shower aide was pulled to work the floor on some days when a CNA was needed.
-When that happens, all CNAs are responsible for giving their assigned residents a bath/shower if it was the residents assigned day.
-The residents were not receiving showers on the bath aide's days off.
-He/she had been working on making sure the residents get their baths/showers on the bath aide's days off by educating the staff that all CNAs are responsible for bath/showers.
-He/she had hired a new bath aide for evenings and they start work on 2/11/25.
-The shower days are to be scheduled days and not moved around to when every they have time to give the bath/shower.
-Some CNAs chart bath/showers in EMR and other CNAs fill out shower sheets and give then to the nurses.
-They go by the standard of care generally two baths/showers per week minimum, unless refused or care plan requests for one bath/shower per week.
MO00249049
MO00249262
Jan 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide oversight and put appropriate interventions in place for o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide oversight and put appropriate interventions in place for one sampled resident (Resident #1) who fell twice on 12/27/24 and sustained head lacerations and then fell again on 1/3/25; failed to ensure fall investigations were completed to include root-cause analysis (RCA-a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) and interventions that were put in place for three sampled residents (Resident #1, Resident #6, and Resident #7); failed to complete neurological checks for one sampled resident (Resident #6) after an un-witnessed fall, and failed to update the care plans for three sampled residents (Resident #1, Resident #6, and Resident #7) to include the interventions that were put in to place after the falls occurred out of seven sampled residents. The facility census was 47 residents.
Review of the facility's policy titled Falls and Fall Risk, Managing dated March 2018 showed:
-A fall was defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force.
-An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught himself/herself.
-A fall without injury was still a fall.
-Unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall would be considered to have occurred.
-The staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.
-If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions.
-In conjunction with the consultant pharmacist and nursing staff, the attending physician would identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even if for a trial period.
-If falls were to continue to occur despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant.
-If underlying causes could not be readily identified or corrected, staff would try various interventions, based on assessment of the nature or category of falling, until was reduced or stopped, or until the reason for continuation of the falling was identified as unavoidable.
-In conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling.
-The staff would monitor and document each resident's response to interventions intended to reduce falling of the risks of falling.
-If interventions were successful in preventing falling, staff would continue the interventions or reconsider whether the measures were still needed if a problem that required the intervention had resolved.
-If the resident continued to fall, the staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions.
-The staff and/or physician would document the basis for conclusions that specific risk factors existed that would continue to present a risk for falling or injury due to falls.
Review of the facility's policy titled Neurological Assessment dated October 2023 showed routine neurological assessments were conducted to evaluate the resident for small changes over time that may be indicative of a neurological injury.
1. Review of Resident #1's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:
- Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, mostly affecting middle-aged and elderly people) with Dyskinesia (abnormality or impairment of voluntary movement).
-Unspecified Convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders).
-Traumatic Brain Hemorrhage (an escape of blood from a ruptured blood vessel) of Left Cerebrum (the largest part of the brain that is divided into two hemispheres) with Loss of Consciousness of Unspecified Duration.
-Muscle Wasting and Atrophy (thinning of muscle mass).
-Old Myocardial Infarction (heart attack- a blockage of blood flow to the heart muscle).
-Difficulty in Walking.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 11/13/24 showed:
-The resident was cognitively intact.
-The resident had no Range-of-Motion (ROM) impairment.
-The resident had not used any mobility devices.
-The resident was independent with all care.
-The resident had not had any falls since admission.
Review of the resident's Fall Risk Evaluation completed on 12/23/24 at 6:07 P.M. showed:
-The resident had one to two falls in the past three months.
-The resident was ambulatory and continent.
-The resident had predisposing diseases including Parkinson's Disease and seizures, which increased his/her fall risk.
-The resident did not take any predisposing medications that would increase his/her risk for falls.
-There were no clinical suggestions noted.
Review of the resident's care plan dated 12/25/24 showed:
-The resident had an Activities of Daily Living (ADLs) self-care performance deficit related to multiple health diagnoses with the resident being able to transfer independently.
-The resident had Parkinson's Disease affecting mobility and staff were to monitor for risk of falls.
-The resident had an actual fall with no injury on 8/31/24 with the following interventions:
--Continue interventions on the at-risk plan.
--Ensure all medications were ordered from pharmacy in a timely manner.
--For no apparent acute injury, staff were to determine and address causative factors of the fall.
--Monitor/document/report Pro re Nata (PRN- as needed) for 72 hours to medical director for signs and symptoms of pain, bruises, change in mental status, and new onset of confusion, sleepiness, inability to maintain posture, or agitation.
--Neurological Checks per facility policy.
--Pharmacy consult to evaluate medications.
--Provide activities that promote exercise and strength building where possible.
-All interventions for falls were placed in the resident's care plan after this initial fall only.
-The resident's fall care plan was not updated upon re-admission or after each fall to include any new interventions that were put in place.
Review of the resident's incident note dated 12/27/24 at 5:00 A.M. that Licensed Practical Nurse (LPN) B completed showed:
-The nurse had been called into the resident's room and found the resident lying to the side of his/her fall mat.
-Blood was coming from the back of the resident's head due to a laceration.
-The nurse applied a pressure dressing.
-Emergency services were called.
-The resident stated that he/she was attempting to get his/her walker so he/she could go downstairs.
-The resident was transferred to a gurney and was awake and alert upon leaving the facility to go to the local hospital.
Review of the resident's Incident Audit Report dated 12/27/24 at 5:00 A.M. showed:
-The resident had an un-witnessed fall.
-The resident had been found on the floor next to his/her fall mat.
-The resident was laying on his/her left side with his/her head propped up by his/her left arm.
-The resident was awake and was apologizing for falling.
-The resident was bleeding from laceration to the occipital region of skull.
-The depth of the laceration was unable to be determined.
-A pressure dressing had been applied.
-The resident stated I was trying to get to my walker to go downstairs. I'm sorry.
-The action that was taken at the time was applying the pressure bandage.
-The resident was normally wheelchair bound.
-The predisposing physiological factors included:
--Confusion.
--Gait imbalance.
--Impaired memory.
--Incontinence.
--Recent change in condition.
--Weakness/fainting.
-No RCA was determined for this fall.
-No interventions post-fall were documented.
Review of the resident's emergency room (ER) Documentation dated 12/27/24 at 7:07 A.M. showed:
-The resident was sent to the ER after a fall.
-The resident was trying to test his/her ambulation.
-The resident complained of right hip pain.
-The resident had a two-inch laceration to the left back side of his/her head.
-The resident had a laceration repair that required two staples.
Review of the resident's Fall Risk Evaluation dated 12/27/24 at 1:05 P.M. showed:
-The resident had three or more falls in the last three months.
-The resident had intermittent confusion.
-The resident was ambulatory and continent.
-The resident did not have any predisposing diseases.
-The resident had a recent change in condition.
-The resident had a balance problem while standing.
-The resident had a balance problem while walking.
-The resident had decreased muscular coordination.
-The resident required the use of assistive devices.
-The resident took one to two predisposing medications including anti-seizure medication that would increase the resident's risk for falls.
-There were no clinical suggestions noted.
Review of the resident's incident note dated 12/27/24 at 4:13 P.M. completed by LPN A showed:
-The nurse was called into the resident's room by the speech therapist.
-The resident was on the floor behind his/her door.
-The resident was on his/her stomach with blood on the floor from the resident's head.
-The resident was awake and alert.
-There was no reported further injury aside from the previous laceration from the fall that morning.
-The resident was assessed and assisted up with two staff members and was placed in his/her wheelchair.
-The nurse applied a pressure dressing to the resident's head to get the bleeding to stop.
-Once the bleeding had stopped, the nurse had attempted to clean the resident's head and hair.
-No new laceration noted.
-The dressing had been placed on laceration along with rolled gauze.
NOTE: There was no investigation or Incident Audit Report completed for this fall.
Review of the resident's Transfer to Hospital Summary dated 12/27/24 at 7:30 P.M. completed by LPN B showed:
-The nurse had approached the resident's room to greet the resident.
-The resident was noted to be laying in bed with his/her pillow saturated in blood.
-The resident had an abdominal (ABD) pad (a specialized medical dressing designed to manage and protect moderate to heavily exuding wounds) wrapped with Kerlix (a white gauze dressing/bandage) as a pressure dressing to his/her head.
-The pressure dressing was completely saturated with blood.
-The nurse alerted the day shift nurse of the finding and alerted the medical director.
-New orders were given to send the resident to the emergency department (ED) for evaluation and treatment due to excessive bleeding.
-The nurse assisted the resident into a sitting position and removed the saturated dressing.
-The nurse assessed the resident's head and found a new laceration.
-The nurse cleansed the wound. Applied a new ABD pad and secured the pad with Kerlix and Coban (a self-adhering bandage).
-The resident was then transported to the local hospital by Emergency Medical Services (EMS).
Review of the resident's ED-Physician Note dated 12/28/24 at 12:10 A.M. showed:
-The resident had been seen in the ED for a fall and that the resident had hit the back of his/her head.
-The resident had a four centimeter (cm) curved scalp laceration in his/her superior (top) occipital region with a small amount of oozing blood.
-The resident received four staples to this area.
-The resident's staples from the previous fall were still intact.
Review of the resident's Health Status Note dated 12/28/24 at 1:00 A.M. completed by LPN B showed:
-He/She had been notified by the local hospital's ED at 12:18 A.M. that the resident was discharging back to the facility.
-The resident had another set of staples placed in order to close the new laceration to the resident's skull.
-The resident arrived back to the facility at 1:00 A.M.
-The resident was transferred to bed from the EMS gurney.
-The nurse educated the resident on the importance of using the call light when in need of assistance.
-The resident stated, I think I learned my lesson.
-The nurse acknowledged the new orders.
Review of a note in the resident's electronic medical record (EMR) dated 12/30/24 at 9:48 A.M. showed:
-A bike helmet was brought in for the resident to wear when out of bed.
-The resident was able to put on and take off the helmet independently.
Review of the resident's admission MDS dated [DATE] showed:
-The resident had moderately impaired cognition.
-The resident had a fall in the last 2-6 months prior to admission.
-The resident had two falls since admission.
-The resident had one fall with no injury.
-The resident had one fall with injury (except major) which included skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains, or any fall-related injury that causes the resident to complain of pain.
-The resident used a wheelchair as a mobility device.
-The resident was able to sit to stand (the ability to safely come to a standing position from sitting in a chair or on the side of the bed) with partial/moderate assistance (helper does less than half the effort).
Review of the resident's Transfer to Hospital Summary dated 1/3/25 at 8:15 P.M. showed:
-The resident was noted to be on the floor to the right side of his/her bed.
-The resident's body was on the fall mat, but the resident's head was pressed up against the wall.
-Blood was noted on the resident's right side of head and forehead.
-A pressure bandage was applied, and the resident was sent to the local ED for evaluation and treatment.
-The resident returned to the facility with no new orders around 2:30 A.M.
-The resident was started on fall follow-up monitoring.
-No specific injury was noted.
NOTE: There was no investigation or Incident Report Audit completed for this fall.
Review of the resident's hospital records dated 1/4/25 at 2:42 A.M. showed:
-The resident had received a Computerized Tomography (CT) Scan of the head and spine with no acute findings.
-The resident had an abrasion to his/her left posterior (back) scalp.
-The abrasion had stopped bleeding.
-The resident showed no signs of distress and was discharged back to the facility.
2. Review of Resident #6's admission Record showed he/she admitted to the facility with the following diagnoses:
-Vascular Dementia (a general term describing problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain).
-Epilepsy (a disorder in which nerve cell activity in the brain is disrupted, causing seizures).
-Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow to the brain).
-Muscle Weakness.
-Unspecified Lack of Coordination.
-Difficulty in Walking.
Review of the resident's quarterly MDS dated [DATE] showed:
-The resident was cognitively intact.
-The resident used a walker.
-The resident was able to move independently.
-The resident had not had any falls since admission.
Review of the resident's Incident Audit Report dated 12/30/24 at 2:30 P.M. showed:
-The resident had an un-witnessed fall.
-The nurse had been alerted by a Certified Nurses Aide (CNA) that the resident was found on the floor.
-The CNA had recently assisted the resident into bed.
-The resident was found sitting on the floor between the legs of the chair with his/her arms above his/her head.
-The resident stated that he/she had pain in his/her left arm, but there were no visible injuries.
-Resident was assisted up by the nurse and two CNAs and into his/her wheelchair.
-The resident had stated that he/she wanted to get up and then fell.
-The immediate actions that were taken:
--Resident was assisted to his/her recliner.
--The resident's bed was adjusted for better clearance of the resident's wheelchair.
--The resident was educated to use his/her call light when feeling weak.
-The report did not include the RCA of the fall.
-NOTE: No neurochecks were completed for a resident who was moderately cognitively impaired.
Review of the resident's undated care plan showed:
-The resident was at risk for falls with a goal for the resident to be free from falls with the following interventions:
--Assist resident with ambulation and transfers.
--Determine the resident's ability to transfer.
--Evaluate fall risk upon admission and PRN.
--If fall occurs, notify provider.
--If fall occurs, initiate frequent neurological assessments and bleeding evaluation per facility protocol.
--If resident was a fall risk, initiate fall risk precautions.
NOTE: The resident did not have an updated care plan related to any actual falls or any fall interventions that were put into place.
A copy of the resident's Neurological Assessments for this fall were requested and not received at the time of exit.
3. Review of Resident #7's admission Record showed he/she admitted to the facility with the following diagnoses:
-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses.
-Muscle Weakness.
-Difficulty in Walking.
-Unspecified Lack of Coordination.
Review of the resident's undated care plan showed:
-The resident had an ADL self-performance deficit related to a recent hospitalization and the resident was able to independently transfer using his/her walker.
-The resident was at moderate risk for falls related to a history of falls prior to admission with a goal that the resident would be free from falls with the following interventions:
-Anticipate and meet the resident's needs.
--Ensure call light was within reach.
--Educate resident/family/caregivers about safety reminders and what to do if a fall were to occur.
--Follow facility fall protocol.
--Review information on past falls and attempt to determine cause of falls.
NOTE: The resident did not have an updated care plan related to any actual falls or interventions that were put into place after falls occurred.
Review of the resident's admission MDS dated [DATE] showed:
-The resident had moderately impaired cognition.
-The resident used a walker and a wheelchair.
- The resident was able to go from sitting to standing with partial/moderate assistance.
-The resident needed partial/moderate assistance to walk ten feet.
-The resident was dependent (helper does all of the effort and the resident does none of the effort to complete the activity) when wheeling more than 150 feet in his/her wheelchair.
-The resident had a fall two to six months prior to admission to the facility.
Review of the resident's Incident Audit Report dated 1/8/25 at 4:05 P.M. showed:
-The resident had a witnessed fall.
-The resident was witnessed by a Certified Medication Technician (CMT) standing at his/her closet hanging up a coat.
-The resident lost his/her balance and landed on his/her buttock.
-The CMT assisted the resident to a lying position with a pillow underneath his/her head.
-The resident was assessed by the charge nurse and no injuries were noted.
-The resident denied any pain.
-The resident was assisted by two staff members onto his/her feet.
-The staff assisted the resident into a chair.
-The resident had not used his/her wheelchair and walker that were in her room and had not called for assistance.
-There were no documented fall interventions that the facility put in place after the fall occurred.
Review of the resident's Incident Audit Report dated 1/17/25 at 9:39 P.M. showed:
-The resident had an un-witnessed fall.
-A nursing aide (NA) had found the resident on the floor in his/her bathroom.
-The resident stated that he/she had tried to take himself/herself to the bathroom and fell.
-The resident had stated that he/she hit his/her head on the door frame.
-The resident had scrapes to his/her knees, but they were not bleeding.
-There was no noticeable injury to the resident's head.
-The resident was assisted up and onto the toilet without difficulty.
-The resident had pain to his/her head.
-The resident became emotional and was upset about not being able to do his/her own things.
-He/She did not want to have to ask the nurses for assistance.
-The resident was educated on the importance of using his/her call light.
-The report did not include the RCA of the fall.
4. During an interview on 1/24/25 at 11:15 A.M. the Director of Nursing (DON) said:
-There was only one incident report for all of Resident #1's falls.
-The nurses had only been doing progress notes for his/her other falls.
-He/She was unaware the fall investigations were not completed.
During an interview on 1/24/25 at 2:24 P.M. CNA A said:
-CNAs were responsible for getting the nurse if they witnessed a fall or if they found a resident on the ground.
-The CNAs could assist in getting the vital signs of the resident and helping the resident up if indicated.
-All care staff could help perform the Neurological Assessments, but the nurses were the ones that completed the assessment and placed the findings in the resident's chart.
-Resident #1 refused to use his/her call light and would get up without staff assistance, causing the falls.
-Resident #1 had fall mats on both sides of his/her bed, but that was the only fall intervention that was put in place that he/she could think of.
-Resident #6's falls normally occurred during the night.
-Resident #6 had difficulty in asking for help but seemed to be getting better.
-He/She remembered that Resident #7 had fallen in the bathroom, and that the resident did not like using his/her call light.
-The fall intervention for Resident #6 and Resident #7 was education related to call light use.
-He/She thought if a resident fell, then neurological assessments were mandated to be completed.
-The neurological assessments were done for 48 hours in total.
-Nurses were responsible for completing the fall investigations and updating the care plan.
-The Administrator was responsible for ensuring the completion of the fall investigations.
During an interview on 1/24/25 at 2:32 P.M. LPN A said:
-He/She had been in the building during one of Resident #1's falls, his/her second fall on 12/27/24.
-Resident #1 had told LPN A that he/she was trying to get up to go to the bathroom.
-Resident #1 would also acknowledge that he/she had not used the call light.
-When he/she assessed Resident #1, he/she could not tell where the resident was bleeding from, so he/she had applied a pressure dressing to the resident's head.
-He/she was unaware the resident had a second injury to the head.
-He/she did not put any interventions in place after the second fall.
-He/She thought neurological assessments were completed for un-witnessed falls.
-The CNAs could get the vital signs for the neurological assessments, but the nurses were responsible for all other parts of the assessment and would document the results in the resident's medical record.
-The facility was not responsible for completing the neurological assessments if the resident was sent to the ER and had a CT scan done with negative findings.
-He/She had only worked at the facility for a month.
-He/She was unsure of the facility's policy related neurological assessments.
-There should have been neurological assessments completed for Resident #6's fall.
-He/She was unsure who completed the fall investigations.
-He/She thought there was a form that the nurses could fill out after a fall occurred, but she was unsure of the facility's policy related to fall investigations.
-He/She expected the CNAs or other floor staff to report all falls to the charge nurse.
-He/She was unsure of the fall interventions that were in place for Resident #1, Resident #6, and Resident #7.
-He/She confirmed the issues with the fall investigations for Resident #1, Resident #6, and Resident #7 as they did not show RCA or specific interventions that were put in place.
-The nurses were not responsible for any part of the care planning process.
-Care plans needed to be updated after every fall that occurred.
-He/She was unsure why Resident #1, Resident #6 and Resident #7 did not have updated care plans.
-Usually care plans would show the date of each fall and the intervention(s) that were put in place.
During an interview on 1/24/25 at 3:05 P.M. the DON said:
-He/She was not present for any of Resident #1's falls.
-The DON was responsible for completing all fall investigations.
-The fall investigations were usually completed in the risk management meetings.
-He/She had been informed that there was no place to put the RCA on the fall investigations and that there needed to be a progress note that included RCA and the intervention that was put into place after each fall.
-He/She confirmed that an RCA was not completed for Resident #1's fall investigation.
-Resident #1 had a bike helmet that was brought in to protect his/her head when out of bed.
-Resident #1 also had the following interventions in place:
--Fall mats.
--His/her bed was moved.
--Frequent checks, meaning the resident was checked on every 15-20 minutes.
--This was not documented anywhere but remembers this being in place for the resident as standard fall precautions.
-Resident #6's intervention was education related to call light usage.
-Resident #7's intervention was for him/her to use his/her wheelchair for mobility.
-The description of action part of the Incident Audit Report could count as the intervention that was put in place after the fall.
-He/She expected the floor nurses to complete the RCA and put interventions in place for each resident fall.
-Social Services was responsible for all aspects of the care plan but had been informed since becoming the DON that he/she could also help with care plans.
-The care plan did not need to be updated after each fall.
-The care plan only needed to be updated if a new intervention was put into place after a fall occurred.
-The nurses were responsible for completing the neurological assessments.
-Neurological assessments were completed after un-witnessed falls.
-The staff did not have to complete neurological assessments when residents came back from the hospital post-fall unless there was a noted head injury.
-The DON ensures completion of the neurological assessments.
-Neurological assessments should have been completed after Resident #6's fall.
During a phone interview on 1/27/24 at 5:44 P.M. Physician A said:
-He/She had been notified after each resident's falls.
-Resident #1 could ambulate on his/her own and had no mobility restrictions.
-He/She thought that Resident #'1 falls were unavoidable, however he/she was unaware that the facility had not been completing thorough fall investigations and were not putting interventions in place after each fall.
-Neurological assessments did not need to be completed for residents who were sent out post-fall.
-He/She expected staff to complete neurological assessments every hour after a fall and he/she would come in the next day to review them.
-He/She was really involved in the resident post-fall care.
-He/She was unsure of specific interventions that were put into place for residents post-fall.
-He/She was unaware that Resident #1 had a bike helmet as part of the resident's fall interventions.
-Anytime a new fall intervention was put into place the staff needed to inform him/her, to be able to approve of the intervention.
-The facility needed to complete thorough investigations of each fall including the root cause of the fall.
-He/She would review medications and do anything needed to mitigate fall occurrences.
-Falls and fall intervention needed to be care planned and updated as needed.
MO00248468
Aug 2024
2 deficiencies
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were adequately groomed by not offeri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were adequately groomed by not offering showers or baths for four sampled residents (Resident #1, #2, #3, and #4) out of seven sampled residents. The facility census was 49 residents.
Review of the facility' s undated Policy, Professional Standards of Care, showed:
-Providing personal care for clients was the primary responsibility of the nursing assistant.
-Often referred to as Activities of Daily Living (ADLs), personal care includes anything that a client needs to maintain hygiene, well-being, self-esteem, and dignity.
-ADLs were the foundation of health and wellness and a part of providing holistic care.
-Standard of two showers a week.
-Residents had the right to refuse.
-(Staff) would have revisited any refusals.
-(Staff) would have care planned residents preference of showers.
1. Review of Resident #1's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses:
-Unspecified fall.
-Dementia (a group of thinking and social symptoms that interferes with daily functioning.
-Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures)
-Transient cerebral ischemic attack (TIA - a brief stroke-like attach that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke).
-Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Muscle weakness.
-Difficulty in walking.
-Unspecified lack of coordination.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 7/18/24 showed:
-He/She was cognitively intact.
-He/She used a walker and wheelchair.
-He/She need substantial assistance for a shower or bath.
Review of the resident's Care Plan dated 5/10/24 showed:
-He/She required assistance to shower safely.
-He/She would like to shower twice weekly, dated 12/28/24.
Review of the residents' shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays.
Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/1/24, 7/24/24 and 7/26/24.
Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24.
Observation and interview on 8/6/24 at 10:10 A.M. showed:
-The resident was still in bed and declined an interview.
-He/She looked unkept and his/her hair was oily in appearance.
2. Review of Resident #2's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses:
-Dementia.
-Unspecified fall.
-Chronic pain.
-Presence of an artificial hip joint.
Review of the resident's Care Plan dated 5/24/24 showed:
-He/She had the potential for falls as evidenced by history of incidents and occasional unsteady gait.
-Staff was to provide assistance required for bathing weekly and as needed.
Review of the resident's quarterly MDS dated [DATE] showed:
-He/She was moderately cognitively impaired.
-He/She used a walker.
-He/She needed moderate assistance to bathe.
Review of the resident's shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays.
Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/30/24.
Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24.
During an interview on 8/6/24 at 10:45 A.M. the resident said:
-He/She does not often get a shower.
-He/She had to clean himself/herself up at the sink.
-His/Her hair felt dirty.
-He/She had refused showers in the past but not for a long time.
-There was not enough staff to give the residents even one shower a week.
3. Review of Resident #3's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses:
-Paranoid schizophrenia (when a person experiences paranoia (fear) that feed into delusions(false belief) and hallucinations (a false perception of objects or events involving your senses; sight, sound, smell, touch or taste).
-Mixed anxiety disorders.
-Osteoarthritis of knee (when the flexible tissue at the end of the bone wears down).
-Edema (water retention).
-Extrapyramidal and movement disorder (a variety of movement disorders as a result of taking antipsychotic drugs usually used to control psychosis (a mental disconnect with reality).
Review of the resident's Care Plan dated 5/24/24 showed:
-He/She had impaired vision.
-He/She required assistance to compete daily activities of care safely related to current conditions.
-Staff was to bathe him/her as per schedule.
Review of the resident's quarterly MDS dated [DATE] showed:
-He/She had debility.
-He/She had a history of TIA.
-He/She had Chronic Obstructive Pulmonary Disease (a group of lung diseases that blocks air flowing making it hard to breathe).
-He/She needed partial assistance to bathe.
Review of the resident's shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays.
Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/1/24 and 7/30/24.
Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24.
During an interview on 8/6/24 at 10:30 A.M. the resident said:
-He/She would like to have had a shower at least weekly, but there was not enough staff.
-He/She would take a sponge bath at the sink but would have liked to have had a shower.
-He/She did not feel as clean when only taking a sponge bath.
-His/Her skin was dry and flaky.
4. Review of Resident #4's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses:
-Osteoarthritis, left hip.
-Heart failure (when the heart does not pump blood as effectively as it should).
-Cardiac arrhythmia (an irregular heart rhythm).
-Pain in left hip.
Review of the resident's annual MDS dated [DATE] showed:
-He/She used a walker and wheelchair.
-He/She needed substantial help to shower or bathe.
-He/She had a debility.
-He/She had cancer.
-He/She had heart failure.
-He/She had Peripheral vascular disease (PVD - a narrowed blood vessel).
-He/She had End Stage Renal Disease (ERSD - the last stage of kidney failure).
Review of the resident's shower schedule showed the resident was scheduled to receive a shower on Wednesdays and Saturdays.
Review of the resident's shower sheets dated July 2024 showed he/she received a shower on 7/17/24.
Review of the resident's records showed there were no showers completed 8/1/24 through 8/6/24.
During an interview on 8/6/24 the resident said:
-He/She does not get regular showers.
-He/She had to wash up at the sink.
-There was not enough staff to get two showers a week like he/she was supposed to have had.
-He/She did not like it.
-His/Her hair was stringy.
5. During an interview on 8/6/24 at 11:45 A.M. Certified Nursing Assistant (CNA) A said:
-He/She did not know how often residents should have been offered a shower.
-There was not enough staff to give the residents a weekly shower.
-The residents were getting a shower once every two weeks.
-There was a shower list which showed which residents were to have received a shower on which day.
-There was a shower sheet and they would document on by writing a S for shower done or R for refused.
-He/She had offered to work extra by coming in an extra day to just give showers and the corporation refused to pay the overtime.
-There was no Shower Aide at this time.
During an interview Graduate Licensed Nurse (GLN) A said:
-The residents should have been offered a shower or bath twice a week.
-At this time the residents were not getting even one shower a week.
-There used to be a Shower Aide but he/she was pulled to work as a CNA on the floor.
-Currently there was no Shower Aide, the CNAs were to give a shower or bath to the residents on their assigned hallway.
-They do not have enough staff to give the residents two showers a week.
-The CNAs know to chart on the shower sheet which then goes to the Director of Nursing (DON).
During an interview on 8/9/24 at 10:53 A.M. Licensed Practical Nurse (LPN) A said:
-The residents should be offered two baths or showers a week.
-They do not have enough staff to give two showers a week.
-They have hired CNAs and Bath Aides and they would not show up for work.
-They did not have a Shower Aide at this time.
-The CNAs were expected to give the residents on the hall that they were working on a shower but they don't have enough help to do that.
-When a resident received a shower the staff should have filled out the shower sheet form and the form was sent to the DON.
During an interview on 8/9/24 at 11:10 A.M. the Administrator said:
-They did not have a Shower Aide currently.
-They start and then do not show up.
-They were currently advertising for a Shower Aide.
-The DON was responsible for ensuring the residents were bathed.
During an interview on 8/9/24 at 12:10 P.M. the DON said:
-The residents should have been offered two showers a week.
-They did not have enough staff to offer two showers a week to the residents.
-Staff should have documented on the shower sheet when a shower or bath was given to the residents.
-If a resident refused then the staff should have documented on the shower sheet and offered a shower at a different time.
-He/She received the list of who was given a shower every month and then it was given to the Administrator.
-Both him/her and the Administrator were responsible for ensuring the residents had the two showers a week and it has not been done as they don't have enough help although they have advertised for a Shower Aide.
-At this time there was not a designated Shower Aide.
-As of today 8/9/24 only one shower had been given to a resident in the month of August.
MO 00239434 and MO 00239041
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 F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to have a certified Infection Preventionalist employed at the facility. The facility census was 49 residents.
The facility did not have a pol...
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Based on interview, and record review, the facility failed to have a certified Infection Preventionalist employed at the facility. The facility census was 49 residents.
The facility did not have a policy for Infection Preventionalist.
Record review of the Administrator's Certificate of Training dated 1/11/24 showed:
-The Administrator had completed the first module of the Infection Prevention and Control Program on 1/11/24.
-No other training was done.
-He/She had not completed the Infection Prevention course.
1. During an interview on 8/6/24 at 12:45 P.M. Graduate Practical Nurse (GPN) A said:
-They have had COVID (a contagious disease caused by the coronavirus SARS-CoV-2) in the building since he/she had started.
-He/She did not know where the Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was stored.
-He/She had not received any education about COVID or what was expected of him/her when a resident became positive.
-He/She did not know if the facility had an Infection Preventionalist.
During an interview on 8/6/24 at 1:45 P.M. the Director of Nursing (DON) said:
-He/She has been doing the Infection Preventionalist's work such as the Antibiotic Stewardship and tracking infections and COVID.
-He/She has not taken the Infection Preventionalist course nor was he/she certified.
-The facility had an Infection Preventionalist but they quit six months ago.
-The facility has been trying to hire an Assistant Director of Nursing (ADON) who would step into that roll, but at present there was no Infection Preventionalist employed at the facility and have not had one for the last six months.
During a interview on 8/9/24 at 10:00 A.M. Licensed Practical Nurse (LPN) A said:
-He/She was the Charge Nurse on the weekends.
-The facility had provided some education on what to do with residents if they became positive with COVID.
-He/She did not think the facility had anyone designated as the Infection Preventionalist.
During an interview on 8/9/24 at 10:30 A.M. the Administrator said:
-Both he/she and the DON were enrolled in the Infection Preventionalist on line class.
-(Documentation showed he/she had completed one module in January 2024).
-They have not had an Infection Preventionalist employed at the facility since February 2024.
-They were trying to hire an ADON who would step into the Infection Preventionalist roll.
Nov 2023
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #22) dignity b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #22) dignity by failing to ensure the placement of the resident's catheter bag (a catheter is a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid into a urinary collection bag) in a dignity/privacy bag so not to expose the contents of the bag out of 12 sampled residents. The facility census was 41 residents.
Review of the facility Dignity policy and procedure dated February 2021, showed each resident should be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. The policy showed:
-Residents are treated with dignity and respect at all times.
-Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
-Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example, helping to keep urinary catheter bags covered.
1. Review of Resident #22's Face Sheet showed the resident was admitted on [DATE] and was readmitted on [DATE], with a diagnosis including hemiplegia (paralysis on one side of the body), dementia (progressive or persistent loss of intellectual functioning and memory loss), stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) with right side weakness, dysphagia (swallowing difficulty), obesity, hyperlipidemia (a high concentration of fat in the blood), long term use of anticoagulants (medications that inhibit coagulation of the blood), bladder dysfunction and urinary tract infection history.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/14/23, showed the resident:
-Had memory loss.
-Needed substantial to total assistance with bathing, dressing and toileting.
-Was frequently incontinent and had a catheter during the lookback period.
Review of the resident's Care plan updated on 9/21/23, showed the resident had incontinence and used a catheter for bladder incontinence due to neurogenic bladder (lack of bladder control). Interventions showed nursing staff would provide good hygiene to the resident after incontinent episodes. The care plan did not show how staff was supposed to store the resident's catheter bag (in a privacy bag or on the floor).
Observation on 11/14/23 from 8:00 A.M. to 9:00 A.M., showed the resident was laying in his/her bed (a low bed) with his/her eyes closed. The resident's catheter bag was laying directly on the floor on the right side of his/her bed and visible from the hallway because the resident's door was open. The catheter bag was not in a dignity/privacy bag and there was yellow fluid inside of the bag. Several staff and other residents were passing by the resident's doorway and none of the staff stopped to check the resident or provided a dignity bag for the resident's catheter bag.
During an interview on 11/16/23 at 12:00 P.M., Certified Nursing Assistant (CNA) A said:
-The resident's catheter bag should always be in a privacy bag and should never be left or placed on the floor with the contents of the catheter bag showing.
-All nursing staff was responsible for ensuring the resident's catheter bag was stored in a dignity bag.
-They have privacy/dignity bags to place the resident's catheter bag in for the bed and wheelchairs and staff have access to the bags or can ask the nurse for them.
During an interview on 11/16/23 at 10:00 A.M., Licensed Practical Nurse (LPN) B said:
-A resident with a catheter should always have their catheter bag covered and in a privacy/dignity bag.
-All nursing staff was responsible for ensuring the resident's catheter bag was stored in a dignity bag.
-The resident's catheter bag should not be uncovered and visible from the hallway and it should not be on the floor.
During an interview on 11/16/23 at 2:32 P.M., CNA J said:
-The resident's catheter bag should always be in a privacy bag.
-All nursing staff was responsible for ensuring the resident's catheter bag was stored in a dignity bag.
During an interview on 11/17/23 at 11:46 A.M., the Director of Nursing (DON) said:
-All catheter bags should be in a privacy bag.
-He/she expected all nursing staff to ensure the resident's catheter bag was stored in a dignity bag and not visible to others.
-Staff would need to look at central supply to see the amount of privacy bags available.
CONCERN
(D)
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, interview, and record review, the facility failed to ensure a resident with a pacemaker had physician's or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with a pacemaker had physician's orders to follow up with cardiology and how often the resident's pacemaker (an electrical device that stimulates the heart at a fixed rate) was to be monitored via the resident's portable cardiac monitor for one sampled resident (Resident #10) out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's policy and procedures for Pacemaker, last revised on December 2015 showed:
-Monitoring:
--Monitor the resident for pacemaker failure by monitoring for signs and symptoms of [NAME] arrhythmias (slow, abnormal heart rhythm).
--The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this.
--Make sure the resident has a medical identification card that indicates he/she has a pacemaker. The medical records must contain this information as well.
-Documentation:
--For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission:
--The name, address, and telephone number of the cardiologist.
--Type of pacemaker.
--Type of leads.
--Manufacturer and model.
--Serial number.
--Date of implant.
--Paced rate.
1. Review of Resident #10's Face Sheet showed no diagnosis for a pacemaker.
Review of the resident's Care Plan dated 9/23/22 showed:
-The resident had a pacemaker with defibrillator (an implanted device that delivers an electric shock to the heart to restore a regular rhythm).
-Machine checks pacemaker per physician orders.
-He/she had a machine in his/her room.
Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 08/15/23 showed:
-The resident had a Brief Interview for Mental Status (BIMS) of 14 out of 15 indicating he/she was cognitively intact.
-No diagnosis of pacemaker.
Review of the resident's Physician's Order Sheet (POS) dated November 2023 showed no physician's orders for pacemaker checks, monitoring, or cardiology follow-up.
Observation of the resident's room showed:
-On 11/13/23 at 8:55 A.M., the pacemaker monitor was unplugged, sitting on top of the spare bed in the resident's room.
-On 11/14/23 at 2:21 P.M., the pacemaker monitor was unplugged, sitting on top of the spare bed in the resident's room.
During an interview on 11/14/23 at 2:21 P.M., the resident said:
-He/she did have a pacemaker.
-He/she unplugged his/her pacemaker monitor a year ago, and has not turned it on since.
Observation on 11/15/2023 at 8:46 A.M., of the resident's room showed the pacemaker monitor was no longer visible.
During an interview on 11/15/23 at 9:26 A.M., the resident said the staff put his/her pacemaker monitor away in the dresser.
During an interview on 11/16/23 at 2:37 P.M., Certified Nursing Assistant (CNA) A said that he/she didn't know anything about the pacemaker monitor. He/she also said he/she did not know if the resident had a pacemaker and thought the monitor may have belonged to the resident's late spouse.
During an interview on 11/16/23 at 3:33 P.M., Licensed Practical Nurse (LPN) B said he/she did not know the resident had a pacemaker.
Observation and interview on 11/16/23 at 3:34 P.M., showed:
-LPN B assessed the resident's left upper chest to verify he/she had an implanted pacemaker.
-He/she was able to feel the pacemaker under the resident's skin and verbalized the resident had a pacemaker.
During an interview on 11/16/23 at 3:35 P.M., the resident said:
-He/she did not know when the pacemaker was checked last.
-He/she went through a nearby hospital for pacemaker checks.
-The pacemaker monitor was in his/her dresser drawer.
-He/she would like to have it interrogated (a way to assess the function of the pacemaker to ensure it is properly conducting electricity to and from the heart) at some time.
During an interview on 11/16/23 at 3:36 P.M., LPN B said the resident's documentation:
-Should have a diagnosis for the pacemaker.
-Should have physician's orders for pacemaker checks.
During an interview on 11/17/23 11:03 A.M., the Interim Director of Nursing (DON) said:
-The resident had a pacemaker.
-If a resident had a pacemaker, he/she would expect to see physician orders for pacemaker monitoring.
-If a resident had a pacemaker, this should be included on the list of the resident's diagnoses.
-If a resident had a pacemaker, he/she would expect to see orders for how often the resident would have a follow up with cardiology, including the cardiology group responsible for interrogating the resident's pacemaker.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the maintenance of one sampled resident's (Resident #18) hair care when he/she could not perform the care by him/herse...
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Based on observation, interview, and record review, the facility failed to ensure the maintenance of one sampled resident's (Resident #18) hair care when he/she could not perform the care by him/herself out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 showed:
-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.
-Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene.
-Appropriate care and services will be provided for residents with the consent of the resident and in accordance with the plan of care.
-Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.
-The resident's response to interventions will be monitored, evaluated, and revised as appropriate.
1. Review of Resident #18's Face Sheet showed he/she admitted to the facility with the following diagnoses:
-Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain).
-Flaccid hemiplegia (paralysis to one side of the body) affecting left dominant side.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 9/17/23 showed:
-The resident was cognitively intact.
-The resident had no behavioral issues related to rejection of care.
NOTE: The section referring to personal hygiene was blank.
Review of the resident's care plan dated 9/21/23 showed:
-The resident was unable to dress him/herself independently.
-Assist him/her with personal grooming as needed including setup at the sink, aide with hair, makeup etc. as needed for completion.
Note: The resident did not have a care plan related specifically to hair care or refusal of care.
Review of pictures taken of the resident on 11/8/23 showed:
-A knot in his/her hair approximately the size of a half dollar coin to the back of his/her head.
-The rest of his/her hair below the knot was matted, which was all of the resident's hair on the back of his/her head.
Observation of the resident on 11/13/23 at 9:38 A.M. showed the resident's hair was in braids with some frizz to the top of his/her head where the braids started.
During an interview on 11/13/23 at 1:43 P.M. the resident said:
-He/she had his/her hair done at the beauty shop recently.
-The beauty shop staff put his/her hair into braids.
-The staff at the facility could not do his/her hair.
-Going out of the facility to get his/her hair done costs money.
-If the facility had all of the supplies needed to do his/her hair, he/she would allow staff to do his/her hair care.
During an interview on 11/16/23 at 1:43 P.M. Certified Nursing Assistant (CNA) B said:
-He/she had tried to help the resident with his/her hair in the past.
-The resident would not allow certain staff to touch his/her hair.
-The resident would go out of the facility to get his/her hair care done.
-The resident normally made his/her own hair care appointments.
-He/she would remind the resident to brush his/her hair and would try to persuade the resident to let someone help him/her to prevent his/her hair from matting.
-There had been a staff member that the resident had allowed to do his/her hair, but they no longer worked at the facility.
-The resident's family had been notified in the past of the resident's care refusal.
-He/she was unsure if the resident's refusals of care were being documented.
-He/she thought it was the nurse responsibility to chart refusal of care.
-He/she thought the care refusal should be documented in the resident's chart and included on the care plan.
During an interview on 11/16/23 at 2:27 P.M. Licensed Practical Nurse (LPN) B said:
-The resident was very picky about who could do his/her hair.
-In the past when he/she got family involved in the resident's hair care he/she was chewed-out by the resident.
-Any refusal of care should be documented in the resident's chart.
-The resident's hair maintenance should be addressed in his/her care plan.
-He/she was aware that the resident's hair care was not getting completed.
-The CNAs would let him/her know when the resident refused any type of care.
During an interview on 11/16/23 at 3:06 P.M. the resident said:
-He/she would need the facility to provide different types of conditioner and combs in order to keep his/her hair maintained.
-The facility staff had offered to do his/her hair in the past, but had refused because the staff were not qualified to do his/her hair.
During an interview on 11/17/23 at 9:54 A.M. the facility's Social Services Designee (SSD) said:
-The resident's hair maintenance had not been brought to his/her attention.
-If he/she had known about the issue she would have reached out to a member in the community to come and do the resident's hair.
-Any time the resident refused care or help should have been documented.
He/she would be able to assist in providing supplies in order for the resident's hair care to be completed in the facility.
-The resident's hair should never be matted.
-No residents had been brought to his/her attention related to getting their hair care needs met.
-The resident's hair preferences and care refusals should be on the care plan.
During an interview on 11/17/23 at 11:52 A.M. the Director of Nursing (DON) said:
-The CNAs were responsible for the resident's hair care.
-The resident's hair care had been an issue in the past.
-The resident's hair should never be matted.
-He/she expected the nurses to document when the resident refused care.
-He/she would expect the resident's care plan to reflect his/her hair preferences and the refusal of certain care.
-He/she was unsure how the facility was managing the resident's hair prior to assuming the role of DON.
MO00227123
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 interview and record review, the facility failed to ensure a fall investigation was complete for one sampled resident (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a fall investigation was complete for one sampled resident (Resident #23) who fell on 8/2/23 to determine the root cause of the fall and to ensure an incident report and/or fall investigation was completed per facility policy for a fall on 8/24/23 in which the resident fell and fractured his/her right hip out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's policy titled Falls and Fall Risk, Managing dated March 2018 showed:
-The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.
-The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.
-The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.
-If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved.
Review of the facility's policy titled Assessing Falls and Their Causes dated March 2018 showed:
-The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.
-Complete an incident report for a resident no later than 24 hours after the fall occurs.
-The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing (DON).
-When a resident falls, the following should be in the resident's medical record:
--The condition in which the resident was found.
--Assessment data, including vital signs and any obvious injuries.
--Interventions, first aid, or treatment administered.
--Notification of the physician and family, as indicated.
--Completion of a falls risk assessment.
--Appropriate interventions taken to prevent future falls.
--The signature and title of the person recording the data.
1. Review of Resident #23's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Acute Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood causing a lack of oxygen in the blood).
-Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Disorder of bone density and structure.
-Chronic Kidney Disease (CKD- a long standing kidney disease based on kidney damage or decreased kidney function for three or more months).
NOTE: No diagnosis of right hip fracture found on face sheet or Physician Order Sheet (POS).
Review of the resident's care plan dated 12/8/22 showed:
-The resident was at risk for falls related to prior fall incidents, poor decision making, and impaired gait/shuffling feet when walking.
-The interventions that were in place at the time were:
--Take the resident's vital signs as scheduled.
--Refer the resident for a pharmacy consult as needed.
--Observe the resident for additional assistive devices/positioning devices as needed.
--Keep the resident and responsible party informed.
--Therapy evaluation and treatment as ordered.
--Assist the resident to keep his/her area free of clutter, including the path to the bathroom.
--Assist the resident with ambulation, toileting and mobility as needed with one person.
--Educate/Encourage the resident not to sit at the edge of the bed.
--Educate/Assist the resident to wear non-skid socks or shoes when up.
--Keep reacher device with in reach as desired by the resident.
--Encourage the resident to use the call light for assistance.
Review of the resident's Fall Risk Evaluation completed on 2/28/23 showed the resident scored a 26 which indicated the resident was at high risk for falls and had fallen once within the last assessment period.
Review of the resident's Fall Risk Evaluation completed on 5/30/23 showed the resident scored a 24 which indicated the resident was at high risk for falls and to continue the current plan of care.
Review of the resident's Incident Report dated 8/2/23 at 12:45 P.M. showed:
-The resident fell trying to get linens from the closet.
-The resident was complaining of ankle pain.
-The resident denied hitting his/her head during the fall.
-The fall was unwitnessed.
-The resident's ankle was assessed by the nurse with no abnormalities.
-A 24 hour follow up report was attached and noted:
--An x-ray had been done of the resident's ankle.
--The resident's foot was red, warm, and had a knot on the top of it.
-There were no abnormalities from the x-ray.
-No investigation was completed to determine the root cause of the fall and/or if further interventions were needed related to the fall.
Review of the resident's discharge Minimum Data Set(MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/24/23 showed:
-The resident was cognitively intact.
-The resident needed supervision (oversight, encouragement, or cueing) when transferring him/herself.
-The resident needed limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) for locomotion off the unit.
-When moving from seated to standing position the resident was not steady, but able to stabilize without staff assistance.
-When walking with an assistive device the resident was not steady, but able to stabilize without staff assistance.
-When turning around while walking the resident was not steady, but able to stabilize without staff assistance.
-When moving on and off toilet the resident was not steady, but able to stabilize self without assistance.
-Since the previous assessment, the resident had one non-injury fall and one major injury fall.
Review of the resident's Nurse Note dated 8/24/23 at 6:40 P.M. completed by Registered Nurse (RN) A showed:
-The resident had been walking back from the dining room to his/her room.
-The resident was pushing his/her wheelchair in front of him/her.
-He/she heard the resident yelling out help and observed the resident sitting up on the floor near his/her wheelchair holding his/her right hip.
-The resident also had two skin tears to his/her right hand.
-The resident was assisted back to his/her wheelchair and to his/her room.
-The resident's right leg and foot were turned outward and the resident would shout in pain upon touching the leg.
-The resident had stated that he/she hit his/her head on the hand rail.
-Upon assessment of the resident's head there were no bumps or cuts observed.
Review of the resident's Telephone Order dated 8/24/23 showed an order for a right hip x-ray and for the resident to be sent to the hospital for evaluation and treatment if the x-ray could not be performed that night.
Review of the resident's nurse's note dated 8/24/23 at 7:10 P.M. showed the resident had been sent to the local hospital for a possible right hip fracture.
Review of the resident's Fall Risk Evaluation dated 8/25/23 showed the resident scored a 21 which indicated the resident was at high risk for falls and to follow the current plan of care.
Review of the resident's Social Service Note dated 8/30/23 showed the resident readmitted the facility from the hospital with the diagnoses of Intertrochanteric (a fracture of the proximal femur that occur between the greater and lesser trochanter) right hip fracture.
Review of the resident's Care Plan dated 9/17/23 showed:
-The resident was at risk for fall incidents due to poor decision making and impaired gait/shuffling feet when walking.
-The resident had fallen on 8/2/23 and the resident was educated on asking for assistance and to wear shoes, not slippers.
-The resident had a fall incident on 8/24/23 and was sent to the hospital with a diagnosis of a right hip fracture.
-The facility would offer therapy upon return from the hospital.
-The resident had fallen attempting to toilet him/herself without assistance and the resident was educated on using the call light when needing assistance.
During an interview on 11/13/23 at 9:24 A.M. the resident said:
-He/she had fallen recently and broke his/her hip due to losing his/her balance.
-He/she was not sure if anything was in place but he/she knew that he/she needed to ask for help, but had been told that prior to his/her fall on 8/24/23.
During an interview on 11/14/23 at 10:01 A.M. the resident said:
-He/she thought it was last month when he/she fell and broke his/her hip.
-It had happened out in the hallway, but could not remember all of the details of the fall.
On 11/14/23 at 2:20 P.M. the incident report/fall investigation from the fall on 8/24/23 was requested and not received.
During an interview on 11/15/23 at 11:05 A.M. the Regional Nurse Consultant said:
-There was no incident report or investigation completed for the fall that occurred on 8/24/23.
-The nurse that had come onto the shift had sent the resident out due to the resident's hip pain.
-He/she was going to have the nurse who was on the shift come in and complete the report.
-Nurses were responsible for completing the incident reports after a resident falls.
-He/she knew an incident report needed to be completed for the fall and was unsure why it had not been completed.
During an interview on 11/15/23 at 11:27 A.M. the MDS Coordinator said:
-If an investigation report was not completed for a fall, then he/she would know about a fall through word of mouth.
-The facility had a meeting each morning and falls from the last 24 hours were discussed.
-The nurses were responsible for completing the incident reports after a resident falls.
During an interview on 11/15/23 at 3:48 P.M. the MDS Coordinator said:
-He/she updated the care plan both times after the resident fell on 8/2/23 and 8/24/23.
-Nurses were able to update the care plan and put interventions in the care plan after a resident fall.
During an interview on 11/16/23 at 1:48 P.M. Certified Nursing Assistant (CNA) A said:
-The nurses were responsible for the fall investigations.
-The resident completed therapy for his/her hip after his/her fall.
-The fall interventions in place for the resident were extra supervision and reminding the resident to use his/her call light.
During an interview on 11/16/23 at 2:33 P.M. Licensed Practical Nurse (LPN) B said:
-Nurses were responsible for completing the incident reports for falls.
-Incident reports were completed after each fall.
-The incident reports for falls should be completed before the nurse leaves the building at the end of his/her shift.
-The nurses were also responsible for completing fall follow-up documentation which would be done in a nurse's note.
During an interview on 11/16/23 at 3:51 P.M. RN A said:
-The resident fell right at the end of his/her shift.
-He/she had been passing medications at the time of the fall.
-He/she thought the nurse coming in after his/her shift was going to complete the incident report from the fall on 8/24/23.
-He/she was unsure if there was a specific policy for when fall investigations/incident reports needed to be completed.
-Nurses were responsible for completing incident reports after each resident fall.
-He/she thought that incident reports should be completed by the end of the nurse's shift.
-He/she was unsure of the specific fall interventions in place for the resident, but knew the resident needed to wear non-skid socks.
-He/She did not want to shift blame onto the on-coming nurse, but they had made an agreement at that time for the on-coming nurse to complete the incident report.
During an interview on 11/17/23 at 11:52 A.M. the Director of Nursing (DON) said:
-He/she would expect nurses to complete an assessment and ensure the resident's safety first after a fall.
-He/she would expect the nurse to document a nurse's note including notification of the physician and responsible party.
-Nurses were responsible for completing incident reports after each fall.
-Nurses were able to put any fall intervention in place after a resident falls, if appropriate.
-He/she would expect an incident report and/or risk management report to be completed by the end of the nurse's shift.
-It would not be appropriate to write an incident report at this time or this week for a fall that occurred in August.
-He/she was unsure of what fall interventions were in place pre/post fall on 8/24/23.
During an interview on 11/29/23 at 12:21 P.M. the resident's Physician said:
-When a resident falls he/she would expect the facility to call him/her to determine the best course of action for the resident.
-He/she was unaware that the facility had not completed the incident report for the fall on 8/24/23.
-He/she was unaware that the facility had not completed the investigations for the falls on 8/2/23 and 8/24/23.
-He/she thought the nurses were responsible for completing the incident reports.
-He/she would have expected an incident report to have been completed for the fall on 8/24/23.
-He/she would have expected an investigation to have been completed for the falls on 8/2/23 and 8/24/23.
-He/she thought it was important for the facility to complete the incident report and investigation in order to determine the cause of the fall.
-When a resident falls he/she would expect an incident report to be completed before the nurse leaves the facility.
-He/she would have expected the DON to ensure that the incident reports and fall investigations were completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the placement of one sampled resident's cathete...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the placement of one sampled resident's catheter (a catheter is a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid into a urinary collection bag) bag in a sanitary manner; to ensure the resident's care plan included catheter care interventions for one sampled resident (Resident #22); and to ensure one supplemental resident's catheter was kept below the resident's bladder during a transfer for one sampled resident (Resident #2) out of 12 sampled residents. The facility census was 41 residents.
Review of the facility Catheter Care policy and procedure dated August 2022, showed the purpose was prevent urinary catheter associated complications, including urinary tract infections. The policy showed:
-Position the urinary catheter drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.
-Be sure the catheter tubing and drainage bag are kept off of the floor.
1. Review of Resident #22's Face Sheet showed the resident was admitted on [DATE], with a diagnosis including hemiplegia (paralysis on one side of the body), dementia (progressive or persistent loss of intellectual functioning and memory loss), stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) with right side weakness, dysphagia (swallowing difficulty), obesity, hyperlipidemia (a high concentration of fat in the blood), long term use of anticoagulants (medications that inhibit coagulation of the blood), bladder dysfunction and urinary tract infection history.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/14/23, showed the resident:
-Had memory loss.
-Needed substantial to total assistance with bathing, dressing and toileting.
-Was frequently incontinent and had a catheter during the lookback period.
Review of the resident's Care plan updated on 9/21/23, showed the resident had incontinence and used a catheter for bladder incontinence due to neurogenic bladder (lack of bladder control). Interventions showed nursing staff would provide good hygiene to the resident after incontinent episodes but did not include how they would care for the catheter. The care plan did not show how staff was supposed to transfer the resident with the catheter bag.
Review of the resident's Physician's Order Sheet (POS) dated 11/2023, showed physician's orders for:
-Catheter care 30 milliliter (ml) bulb re-initiate for urinary retention and change monthly and as needed (ordered on 11/2/22).
-Urinalysis and culture (tests to identify bacteria in the urine if indicated due to cloudy odorous urine (ordered on 11/5/23).
Review of the resident's lab urinalysis with culture dated 11/9/23, showed the resident's urine was cloudy, with few abnormal bacteria and clumps present. The result noted probable contamination. The resident's physician was notified.
Review of the resident's Physician's Telephone Order (PTO) dated 11/12/23, for an antibiotic to treat a urinary tract infection.
Observation on 11/15/23 at 1:34 P.M., showed the resident was sitting up in his/her wheelchair dressed for the weather watching television in his/her room. The resident's catheter bag was below his/her bladder in a privacy bag on his/her wheelchair. Certified Nursing Assistant (CNA) J and CNA C both washed their hands upon entering the resident's room and turned off the water with a paper towel. They both donned gloves. CNA J removed the foot pedals from the wheelchair and pulled the mechanical lift in front of the resident. He/She removed the catheter bag from the privacy bag and attached it to the lift sling which below the resident's bladder. CNA J and CNA C both attached the sling (that was under the resident) to the lift. CNA C lifted the resident into a standing position while CNA J assisted with safety and positioning. The resident was able to hold onto the lift and stand safely. They moved him/her to her recliner and lowered him/her into the chair, then removed the sling. CNA J then took the catheter bag off of the lift, hung it on the side of the trash can while CNA C removed the privacy bag from his/her wheelchair and handed it to CNA J. CNA J then removed the catheter bag from the side of the trash can and placed it into the privacy bag at the side of his/her recliner. CNA C de-gloved and washed his/her hands and removed the lift. CNA J de-gloved, washed his/her hands and turned off the water with a paper towel before leaving the room.
2. Review of Resident #2's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including seizures (a sudden, uncontrolled burst of electrical activity in the brain), stroke, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), obesity, high blood pressure, arthritis and hemiplegia.
Review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert and oriented.
-Was dependent on nursing staff for bathing, dressing, mobility and toileting and was incontinent.
Review of the resident's Care Plan dated 11/3/23 showed the resident had a catheter for neurogenic bladder. Interventions showed the nursing staff was to:
-Assess the resident's urine clarity and assess for infection.
-Secure the catheter tubing to his/her thigh to prevent pulling.
-Change the catheter and tubing/bag a scheduled.
-Provide catheter care after every shift and monitor for kinks/twists in the tubing.
-The care plan did not show how/where the catheter bag should be placed.
Review of the resident's POS dated 11/2023, showed physician's orders for placement of a urinary catheter for urinary retention (ordered 11/3/23).
Observation on 11/14/23 at 9:40 A.M., showed CNA J and Nursing Assistant (NA) A both washed their hands and dried them, turning off the water with a paper towel, and both donned gloves. CNA J and NA A attached the sling to the lift the CNA J hung the resident's catheter bag onto the sling, which was above the resident's bladder, and lifted the resident while NA A assisted with the resident's positioning and safety. CNA J lowered the resident onto his/her bed and placed the resident's catheter bag at the foot of the bed at the level of the resident's bladder. Both CNA J and NA A removed their gloves, sanitized their hands and put on new gloves, then rolled the resident to the side to remove the sling from underneath him/her. CNA J then removed the resident's catheter bag from the bed and placed it in the privacy/dignity bag that was at the side of the resident's bed which was below his/her bladder. CNA J changed the resident's trash, de-gloved and sanitized his/her hands. NA A lowered the resident's bed and placed his/her tray table and call light beside him/her. They both washed their hands prior to leaving the resident's room.
During an interview on 11/16/23 at 12:00 P.M., CNA A said:
-The catheter bag should always be below the bladder but not on the floor.
-During a transfer they should hold the catheter bag below the bladder.
-When he/she transfers a resident using a lift, one person operates the lift and the other should either hang the bag in low position below the resident's bladder until they complete the transfer and then place it in the privacy bag or hold it below the bladder until they complete the transfer and place it below the bladder in the privacy bag.
-The catheter bag should never be above the resident's bladder.
During an interview on 11/16/23 at 2:32 P.M., CNA J said:
-The catheter bag should never be on the floor.
-The catheter bag can be placed on a towel on the floor (to keep it off of the floor).
-If the catheter bag is on the floor, they should notify the nurse to change the catheter bag (due to possible cross contamination).
-During incontinence care, he/she thought they could hang the bag on the side of the trash can or on a towel on the resident's bed until they were able to put it into the privacy/dignity bag.
-The resident's catheter should always be below his/her bladder.
-Most of the catheter bags have a backflow valve, according to what the nurses have told him/her but he/she was not able to identify the backflow valve on the catheter bag.
-Generally, they would keep the resident's catheter bag below the resident's bladder so the urine does not flow back into the resident's bladder, which can cause infections.
-During a transfer, he/she was told that it was okay to hang the resident's catheter bag on the trash can, but he/she did not think that it was very sanitary and could cause cross contamination.
-During the transfer of Resident #2, he/she was told that he/she could hang the bag on the sling at the lowest setting where it is not above the resident's bladder and it does not get caught or pulled.
-Resident #2 preferred the nursing staff hang his/her catheter bag on the sling during his/her transfers to keep them from tugging on the catheter tubing.
During an interview on 11/16/23 at 10:00 A.M., Licensed Practical Nurse (LPN) B said:
-The catheter bag should be kept below the resident's bladder but should never be on the floor.
-During a transfer, the resident's catheter bag should be kept below the resident's bladder at all times.
-The resident's catheter bag should never be hung on the trash can.
During an interview on 11/17/23 at 11:46 A.M., the Director of Nursing (DON) said:
-The resident's catheter should be below the resident's bladder at all times.
-The resident's catheter bag should not be hung on the trash can.
-During a transfer, the resident's catheter bag can be hung on the sling as long it is at the waist or below.
-Staff were able to hold the resident's catheter bag during a transfer as long as it is below the resident's waist.
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, interview, and record review, the facility failed to ensure dialysis (a life-saving procedure to remove waste products and excess fluid from the blood when the kidneys stop worki...
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Based on observation, interview, and record review, the facility failed to ensure dialysis (a life-saving procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services were provide per the physician's order; and to ensure an order for the bandages to be removed from the access (the connection of an artery and vein used as a way to reach the blood to perform dialysis) after dialysis, were present for one sampled resident (Resident #27) out of 12 sampled residents. The facility census was 41 residents.
A policy was requested on 11/16/23, in writing to the Administrator, and was not received at time of exit.
1. Review of Resident #27's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 10/20/23, showed:
-The resident was dependent on dialysis.
-The resident was cognitively intact.
Review of the resident's undated Care Plan showed staff were to monitor the resident's dialysis access.
Review of the resident's Physician's Orders, dated November 2023, showed the physician ordered staff to monitor the resident's dialysis access for bruit (sound of blood rushing through the access) and thrill (a rumbling sensation felt when touching the access) every shift on 10/1/22.
Review of the resident's Treatment Administration Record (TAR), dated November 2023, showed staff failed to document any monitoring for the resident's dialysis access 18 out of 25 times for the month.
During an interview on 11/15/23 at 1:21 P.M., the resident said:
-Staff did not remove the bandages from his/her dialysis access.
-A former therapist at the facility had removed his/her bandages but when the therapist left the facility, the staff told him/her to do it himself/herself because they didn't like to see blood.
-Staff had never listened to or felt his/her dialysis access for bruit and thrill.
-He/she would not know if the access was unusable until he/she arrived at the dialysis clinic as the dialysis clinic nurses were the only one to check his/her access for bruit and thrill.
During an interview on 11/15/23 at 1:25 P.M., the Dialysis Clinic Registered Nurse (RN) said:
-The resident did occasionally come to dialysis with bandages still on his/her access.
-The resident had required a few fistulograms (an x-ray procedure used to view a fistula when there are complications and dialysis cannot be adequately performed) in the past year.
During an interview on 11/16/23 at 11:07 A.M., Certified Medication Technician (CMT) C said:
-Blanks on the TAR meant the care was not provided.
-Only nurses could perform dialysis access care.
During an interview on 11/16/23 at 11:16 A.M., Licensed Practical Nurse (LPN) B said:
-He/she expected the physician's orders to be followed.
-Nurses were to document dialysis access care on the TAR.
-Nurses were responsible for removing dialysis access bandages.
During an interview on 11/17/23 at 12:06 P.M., the Director of Nursing (DON) said:
-Blanks on the MAR and TAR meant staff were unable to verify if the task had been completed.
-Some residents removed their own dialysis access bandages and some did not.
-He/she expected a physician's order to be present for removing dialysis access bandages.
-He/she believed it was important for nursing staff to remove the dialysis access bandages to monitor for infection, bleeding, or occlusion (blockage of blood flow in the access).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive plan and offer appropriate foo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive plan and offer appropriate food choices for one supplemental resident (Resident #26) to assist in losing weight out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's policy entitled Weight Assessment and Intervention dated 3/22, showed:
- Resident weights are monitored for undesirable or unintended weight loss or gain.
- Residents are weighed upon admission and at intervals established by the interdisciplinary team.
- Any weight change of 5% or more since the last weight assessment was retaken.
- Unless notified of significant weight change, the Registered Dietitian (RD) will review the unit record monthly to follow individual weight trends over time.
- Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation included the resident's target weight range, the resident's calorie protein and other nutrient needs compared with the resident's current intake
- The relationship between current medical condition or clinical situation and recent fluctuations in weight;
- Whether and to what extent weight stabilization or improvement can be anticipated.
- Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the RD, the consultant pharmacist, the resident and/or resident's legal surrogate.
- Individualized care plans shall address to the extent possible the identified causes of weight loss, the goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment.
- Interventions for undesired weight gain consider resident preferences and rights, a weight loss regimen will not be initiated for a cognitively capable resident without his/her approval and involvement
- If a resident declines to participate in a weight loss goal, the RD will document the resident's wishes and those wishes will be respected.
1. Review of Resident #26's Nutritional Progress Note completed by the RD dated 6/20/23, showed:
-The resident was referred to the RD.
-The resident stated to the RD he/she wanted more fresh fruit and vegetables and the meals had too many carbohydrates.
-The resident had some fresh fruit in his/her room.
-The resident spoke to the RD about having more fresh fruit and vegetables for meals and snacks.
Review of the resident's assessment dated [DATE], completed after the resident's readmission, showed:
- Medications used included diuretics (medicines that help reduce fluid buildup in the body), psychotropics (a group of drugs (antidepressants, antianxiety medications, antipsychotics, and stimulants) that doctors may prescribe to treat a variety of conditions), Insulin (an important part of diabetes treatment which helped in keeping blood sugar under control and prevented diabetes complications. It works like the hormone insulin that the body usually makes),
- The resident had a regular diet order.
- The resident had no potential risk factors or referral criteria at time of screening.
- Evaluation of needs recommendations/interventions.
Review of the Resident Council Minutes dated 8/8/23, showed the resident who attended the Resident Council meeting, inquired about different kinds of food choices, but the Staff Liaison (the Activity Director) reminded the residents that the price of groceries were going up.
During an interview on 11/16/23 at 10:07 A.M., the Activities Director said:
- Some residents have asked for fruit during the resident council meetings.
- He/she had to remind the residents that the price of groceries (food items for the dietary department) were increasing.
- He/she has heard of increased prices for groceries, from the facility leadership at the Administrative meetings.
Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning), dated 9/13/23, showed:
- The resident made himself/herself understood and understood others.
- A resident who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15.
- A resident had no swallowing disorders or any special nutritional approaches.
Review of the resident's Care Plan reviewed on 9/25/23 showed:
- Problem: The resident was risk for impaired mobility as evidenced by a good appetite the resident was overweight due to excessive oral intake with little motivation for activity. The resident has spoken about wanting to lose weight, but weight loss had not been successful.
Goal: The resident will have gradual weight loss to improve mobility during the next 90 days.
Approaches included: Notify the physician if the resident has a significant weight loss; provide the resident the diet as ordered; provide the resident with snacks or supplements; Provide the resident with his/her preferred food and beverages such as coffee with creamers; resident dislikes fish, but likes toast, sausage, eggs, milk, oatmeal.
Review of the summary of the Resident's Telecare progress note dated 10/3/23, showed:
- The resident's chart was reviewed with facility staff.
- The resident reported an involuntary weight gain since his/her admission in 6/20.
- The resident appeared disheveled, overweight and alert.
- A care plan meeting was discussed and the resident stated he/she was on too much medication, was tired and complained about the food.
- No mention of any plans or diagnoses related to the resident's weight.
Review of the resident's Physicians Order Sheet (POS) dated 11/23, showed diagnoses which included: Congestive Heart Failure (CHF- a long-term condition in which your heart can't pump blood well enough to meet your body's needs), Unspecified edema (swelling caused by too much fluid trapped in the body's tissues), hypokalemia (a lower than normal potassium level in your bloodstream), hyperlipidemia (the presence of too many lipids (or fats) in the blood), such as cholesterol and triglycerides) acquired absence toes on his/her right foot.
Review of the resident's vital signs and weight record showed the following monthly weights from 4/23 through 11/23:
- On 4/5/23, a weight of 465.0 pounds (lbs.) was recorded.
- On 5/23 (no specific date recorded), no weight was recorded.
- On 6/23, a weight of 464.0 lbs. was recorded.
- On 7/23, a weight of 476.0 lbs. was recorded.
- On 8/23, a weight of 477.5 lbs. was recorded.
- On 9/23, a weight of 469.0 lbs. was recorded.
- On 10/23, no weight was recorded due to resident refused over 5 days.
- On 11/1/23, a weight of 470 lbs. was recorded.
Review of the resident's Medical record showed the absence of a food likes and dislikes assessment.
Observation during the lunch meal preparation on 11/13/23 from 11:20 A.M. through 11:35 A.M., showed the absence of any fresh fruits and vegetables from any of the plates which were fixed for any of the residents.
During an interview on 11/13/23 at 11:42 A.M., the resident said:
- The facility served him/her too many carbohydrates.
- The facility needed to serve fresh vegetables such as zucchini, broccoli and/or cauliflower and fresh fruit such as bananas, strawberries, blueberries, blackberries, kiwi fruit and oranges.
- He/she wanted more foods with a high protein content.
- He/she did get some proteins with his/her meals but not as much as he/she would like.
- The facility has not completed a dietary assessment of his/her dietary likes and dislikes.
- He/she would like to have a salad once per day.
- He has discussed losing weight with several people.
- No one from the facility came back to him/her to develop a plan on how to lose weight.
During an interview on 11/16/23 at 10:31 A.M., the Regional Nurse Consultant said:
- At this time they do not always have substitutions such as salads for lunch.
- The facility has been adding in fresh apples and bananas to the menu.
- The facility was trying to obtain an assessments of food likes and dislikes for all residents at that time.
-The corporation has a set Per Person Day (PPD) pricing.
- Moving towards more of a resident centered approach will cut down on wasted foods.
During an interview on 11/16/23 at 11:51 A.M., Licensed Practical Nurse (LPN) B said:
- The resident's desire to lose weight was discussed in the past.
- The menu has too many carbohydrate choices.
- The residents really do not have all the food options they are supposed to have.
During a phone interview on 11/17/23 at 1:46 P.M. the Consultant RD said:
- The resident had expressed a desire for more fruits and more vegetables.
- The resident had expressed a desire to lose weight.
- The resident said he/she wanted a salad for lunch.
- Upon knowing that information, he/she would speak with the resident about decreasing his/her carbohydrate intake.
- He/she would write a different kind of dietary recommendation for that resident.
-The budget allotted to purchase food, may be too restrictive to not allow the dietary department to purchase more fruits and veggies.
-The information regarding the resident's likes and dislikes, was not in the chart for him/her to review.
-He/she showed the Dietary Manager the form that he/she was supposed to use to obtain the resident's food likes and dislikes.
- He/she would communicate with MDS Coordinator, the DON, and the Administrator Admin.
- He/she did not communicate directly with the physicians.
- Residents were referred to him/her based on the following criteria: new admissions. readmissions, residents who were due for annual or significant change MDS's, residents with weight loss residents who may have pressure wounds, and residents who have dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) patients.
- If the facility refers a resident to him/her, then he/she will assess that resident.
During a phone interview on 11/21/23 at 9:11 A.M., Physician A said:
- On each monthly visit, he/she typically spends about 15 minutes with a resident.
- If there was a problem with a resident, and he/she was notified, he/she will see that resident.
- The resident has expressed a desire to lose weight at almost every visit.
- Diet was very important.
- The facility cannot implement a special diet due to culture change.
- He/she has advised the resident to eat less carbohydrates, eat less fat eat more protein, and cut back on the meal portions.
- The residents can order a healthy menu.
- The residents can chose menu items.
During a phone interview on 11/27/23 at 1:18 P.M., Former Director of Nursing (DON) A said:
- He/she was a DON at the facility for two weeks (8/1/23 through 8/12/23).
- The RD had no contact with him/her to discuss the resident's issues.
During a phone interview on 11/28/23 at 11:24 A.M., Former DON B said:
- He/she was a DON at the facility from the middle of January 2023 through the middle of June 2023.
- There was not really a plan for the resident to lose weight.
- He/she did not remember if the RD assessed the resident or not.
- He/she spoke with the resident about making healthy food choices.
- The resident spoke to him/her about having a salad at lunch.
- Fresh fruit was not often available at the facility, when he/she worked at the facility.
- The facility had fresh vegetables available on an intermittent basis but not regularly.
- The facility should be offering healthy food choices.
During a phone interview on 11/29/23 at 1:15 A.M. Physician A said:
- He/she did not attend the interdisciplinary care plan meetings.
- Most nursing homes will complete the care plans, then the nursing home would send the plan to him/her for approval.
- He/she has referred the resident to a gastric bypass surgeon and that surgeon has told him/her the resident needed to lose 75 pounds to qualify for the surgery.
- When he/she visits with the resident, he/she often reminded the resident about making healthy food choices and increasing physical activity.
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 observation and interview, the facility failed to maintain the flooring in the restroom of resident room [ROOM NUMBER],...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the flooring in the restroom of resident room [ROOM NUMBER], in good repair; to maintain sprinkler heads in the dining room free of cobwebs; and to maintain the fan in resident room [ROOM NUMBER] and at the North nurse's station free of a dust buildup. This practice potentially affected at least 25 residents who resided in or used those areas. The facility census was 41 residents.
1. Observation on 11/14/23 at 9:37 A.M., with the Maintenance Director and the Housekeeping Supervisor, showed a 29 inch (in.) long section of flooring peeled away from the layer of floor underneath, in resident room [ROOM NUMBER] restroom.
During an interview on 11/14/23 at 9:40 A.M., the Maintenance Director said the floor in resident room [ROOM NUMBER] was not in the maintenance log book to be repaired.
2. Observation on 11/14/23 at 10:40 A.M., with the Maintenance Director and the Housekeeping Director, showed the presence of cobwebs (a spider's web, especially when old and covered with dust) in the dining room.
During an interview on 11/14/23 at 10:40 A.M., the Housekeeping Supervisor said a brush with a longer handle could be used to clean off the sprinkler heads.
3. Observation on 11/14/23 at 11:05 A.M., with the Maintenance Director and the Housekeeping Supervisor, showed a heavy buildup of dust on the fan blades in resident room [ROOM NUMBER].
4. Observation on 11/14/23 at 11:14 A.M., with the Maintenance Director and the Housekeeping Supervisor showed a dust on the fan at the north Nurse's station.
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
Based on interview and record review, the facility failed to follow facility policies and procedures for completing criminal background checks (CBC) within a timely manner and in accordance with the r...
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Based on interview and record review, the facility failed to follow facility policies and procedures for completing criminal background checks (CBC) within a timely manner and in accordance with the requirements prior to employing five of 10 employees sampled for the criminal background screening. The facility census was 41 residents.
Review of the facility's undated Background Screening policy and procedure showed the facility conducts background screening checks, reference checks and criminal conviction investigation checks on applicants with direct access to residents. The procedure showed:
-For purposes of this policy, direct access means any individual who has access to a resident patient of a long term care facility or provider through employment or through a contract and has duties that involve one on one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program.
-The director of personnel or designee conducts background checks, reference checks and criminal conviction checks on all potential direct access employees and contractors.
-Background and criminal checks are initiated within two days of an offer of employment or contract agreement and are completed prior to employment.
1. Review of five employee records on 11/16/23, showed:
-Dietary Aide D was hired on 2/2/23; the documentation showed the facility staff did not request the CBC.
-Registered Nurse (RN) A was hired on 4/17/23; documentation showed the facility staff did not request the CBC.
-Licensed Practical Nurse (LPN) D was hired on 6/1/23; documentation showed the facility staff did not request the CBC.
-Certified Nursing Assistant (CNA) C was hired on 6/5/23; documentation showed the facility staff did not check the CBC.
-CNA H was hired on 5/12/23; documentation showed the facility staff did not request the CBC.
During an interview on 11/28/23 at 1:07 P.M. the Administrator said:
-They were not able to find the CBC checks that were requested on these residents.
-Dietary Aide D and CNA C were rehired to the facility.
-The Human Resource Manager was under the impression that if the facility registered the employees on the Family Safety Care Registry site, then they were also running the Criminal Background Check.
-He/she was not aware that the CBC should be run separately from registration on the Family Safety Care Registry site.
-They did not have documentation showing they ran the Criminal Background Checks on the employees noted.
-They had run the Employee Disqualification List and Nurse Aide Registry checks on these employees.
CONCERN
(E)
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** 2. Review of Resident #3's Face Sheet showed the resident had a diagnosis of glaucoma (a condition of increased pressure inside ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #3's Face Sheet showed the resident had a diagnosis of glaucoma (a condition of increased pressure inside the eye which could lead to blindness).
Review of the resident's Care Plan showed the resident was at risk for impaired vision related a left corneal transplant dated 12/29/21.
Review of the resident's Nursing Notes dated 6/13/23 showed he/she returned from an outside surgical appointment for a corneal transplant (an operation to replace part of the cornea from a donor. The cornea plays a large part in the eye's ability to see clearly) on his/her right eye.
Review of the resident's Quarterly MDS dated [DATE] showed:
-He/she scored 10 out of 15 on the Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 1 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation, and ability to register and recall new information. These items are crucial factors in care planning decisions) indicating the resident was moderately cognitively impaired.
-He/she had no wounds at that time.
Review of the resident's August 2023 POS showed a physician's order for weekly skin assessment by licensed nurse every Tuesday, dated 5/4/23.
Review of the resident's August 2023 TAR showed the resident had one skin assessment documented out of four opportunities. No mention of dark circles under the resident's eye(s).
Review of the resident's Nurses Progress Notes showed:
-On 8/3/23, bruising was noted below the resident's right eye.
-On 8/4/23, bruising was noted below the right eye.
-On 8/7/23, faded bruising was noted below the right eye.
-On 8/8/23, the area under the resident's right eye was green in color, fading from a fall.
-On 8/8/23, faded bruising was noted below the right eye area.
Review of the resident's September 2023 POS showed weekly skin assessment by licensed nurse every Tuesday, dated 5/4/22.
Review of the resident's September 2023 TAR showed:
-Staff documented the resident had a skin assessment on 9/6/23, 9/26/23, and 9/30/23.
-The back of the form showed no skin issues was noted on 9/6/23 with no further notations or descriptions for the additional assessments.
Review of the resident's October 2023 POS showed physician's orders for weekly skin assessment by a a licensed nurse every Tuesday, dated 5/4/22.
Review of the resident's October 2023 TAR showed no documentation by the facility staff the resident's weekly skin assessment was completed four out of four opportunities.
Review of the resident's Skin Monitoring: Comprehensive CNA) Shower Review dated 10/23/23 showed no documentation of abnormal looking skin which included no bruising and no abnormal color.
Review of the resident's November 2023 POS showed weekly skin assessment by licensed nurse on Tuesdays, dated 5/4/22.
Review of the resident's November 2023 TAR showed no documentation by the facility staff the resident's weekly skin assessment was completed two out of four opportunities.
--No documentation by the facility staff related to the resident's discoloration below his/her right eye observed by the surveyors between 11/13/23 - 11/17/23.
Observation and interview on 11/14/23 9:53 A.M., of the resident in the Physical Therapy room showed:
-He/she had discoloration under his/her right eye.
-He/she said he/she did not know why he/she had discoloration under his/her right eye.
Observation on 11/15/23 at 8:51 A.M., showed the resident's dark circle under the right eye was slightly less pronounced than on the previous day.
During an interview on 11/15/23 at 12:42 P.M., the resident was unable to say what happened to cause the dark circle under his/her right eye.
Observation on 11/16/23 at 9:08 A.M. showed the resident's dark circle under his right eye was less noticeable.
During an interview on 11/16/23 at 11:37 A.M., Certified Medication Technician (CMT) A said:
-The resident does not have a black eye.
-He/she will have a dark circle under his/her eyes, due to his/her thin skin and pale skin tone.
-The resident rubs his/her eyes often.
-The color under his/her eye will fluctuate when he/she is not feeling well, or if he/she is tired.
-When the resident is tired, his/her pale skin gets paler and the shadows under his/her eyes get darker.
-The resident just got over pink eye.
During an interview on 11/16/23 at 2:32 P.M., CNA A said whenever resident's allergies act up, the discoloration under his/her eye looks darker.
During an interview on 11/16/23 at 2:32 P.M., the resident said the skin under his/her eye has been discolored since he/she had surgery on his/her eye several months ago. He/She denied any injury to his/her eye and motioned he/she rubbed his/her eyes frequently.
During an interview on 11/16/23 3:06 P.M., LPN B said:
-The resident had discoloration under his/her right eye for as long as he/she can remember.
-The resident has a pale complexion, which makes the discoloration even more noticeable.
-The resident has never reported any injury to his/her right eye.
-He/she is the person who does the skin assessments for this resident. The nurse that is in charge is the person responsible to document the weekly skin assessment on the resident's TAR.
-He/she had not documented the discoloration under the resident's eye since it was not an injury, it just seemed to be part of his/her complexion.
-Documenting wounds should be done on the back of the MAR/TAR using the body picture to locate wounds. If there are no issues, the nurse leaves the body picture blank, and puts a note under the weekly summary. If there was was a wound, the nurse draws the wound on the body picture and adds the information to the weekly summary. One sheet should show an entire month's worth of assessments.
-There are no skin assessments for the last several months. If it was done, then it should be documented on the front of the MAR/TAR.
During an interview on 11/17/23 at 11:04 A.M., the Interim Director of Nursing (DON) said:
-He/she has seen discoloration around the resident's eyes.
-It was a chronic condition for the resident and was not due to an injury.
-The resident did not have a black eye.
-Staff should document the weekly skin assessments on the resident's TAR.
3. Review of Resident #10's Face Sheet showed the resident was admitted with a diagnosis of peripheral vascular disease (disease of the arteries and veins of the extremities).
Review of the resident's Care Plan dated 9/21/20 showed:
-The resident was at risk for skin impairment due to lower extremity edema (swelling) and lower extremity discoloration dated 9/23/22 and updated 8/29/23.
-On 10/30/23 resident was at risk for swelling in legs and arms due to a diagnosis of end stage renal failure renal (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes).
-Inspect resident's skin for changes during daily cares dated 8/29/23
-Provide weekly skin audit by licensed nurse per schedule and as needed dated 8/29/23.
-Monitor and report any excessive bleeding or bruising noted dated 8/29/23.
Review of the resident's July 2023 POS showed physician's orders for weekly skin assessment by licensed nurse every Wednesday dated 10/14/20.
Review of the resident's July 2023 TAR showed:
-Weekly skin assessment by licensed nurse every Wednesday. No documentation by facility staff for this was completed one out of four opportunities.
-On 7/5/23 staff documented: Skin check complete. Bilateral lower extremities had a dark purple color to them and the skin was fragile due to circulation.
-On 7/26/23 staff documented: skin check complete. Bilateral lower extremities were dark purple and the skin was fragile.
-Notations on the body drawing at the bottom right corner of the skin assessment sheet showed staff documented many bruises on bilateral forearms front and back and purple in color on bilateral lower extremities front and back.
Review of the resident's August 2023 POS showed a weekly skin assessment to be completed by a licensed nurse every Wednesday dated 10/14/20.
Review of the resident's August 2023 TAR showed:
-Weekly skin assessment by licensed nurse every Wednesday. No documentation by facility staff for this was completed on four out of five opportunities.
-No documentation on the back of the form with a description of the resident's skin five out of five opportunities.
Review of the resident's September 2023 POS showed physician's orders for weekly skin assessment by a licensed nurse every Wednesday dated 10/14/20.
Review of the resident's September 2023 TAR showed:
-Weekly skin assessment by licensed nurse every Wednesday. No documentation by facility staff was completed for two out of four opportunities.
-Staff documented on the back of the TAR all areas healed of skin issues dated 9/7/23. No further descriptions of the resident's skin were documented.
Review of the resident's October 2023 POS showed a physician's orders for weekly skin assessment by licensed nurse every Wednesday dated 10/14/20.
Review of the resident's October 2023 TAR showed:
-Weekly skin assessment by license nurse every Wednesday. No documentation by facility staff was completed for four out of four opportunities.
-No documentation on the back of the form with a description of the resident's skin four out of four opportunities.
Review of the resident's November 2023 POS showed physician's orders for weekly skin assessment by a licensed nurse every Wednesday, dated 10/14/20.
Review of the resident's November 2023 TAR showed:
-Weekly skin assessment by licensed nurse every Wednesday. No documentation by facility staff was completed for three out of three opportunities.
-No documentation on the back of the form with a description of the resident's skin three out of three opportunities.
Observation on 11/13/23 at 8:56 A.M., and 12:32 P.M. of the resident showed:
-The resident's legs had purple/bluish discoloration with slight edema.
-His/Her forearms had scattered purple/bluish and red discoloration.
Observation on 11/16/23 at 2:37 P.M. showed:
-The resident had scattered purple/bluish discoloration to his/her forearms.
-The resident had purple/bluish discoloration to his/her lower extremities.
-CNA A said this was the resident's normal coloring.
During an interview on 11/17/23 at 10:52 A.M., the interim DON said:
-Skin assessments should be documented on the resident's TAR with details by the nurse caring for the resident.
-If a resident has issues that come and go, like discoloration, it should be documented on the weekly skin assessments.
-Primarily the skin assessment details are supposed to be on the resident's TAR. Skin is also assessed on the bath sheets.
-Documentation of skin assessments and descriptions was hit and miss of what it looks like.
-He/she was not sure who, if anyone, was auditing to ensure weekly skin assessments were completed.
Based on observation, interview and record review, the facility failed to follow and document physician ordered wound treatments for one sampled resident (Resident #34) with a diabetic heel wound, and to ensure weekly skin assessments were completed per physician orders for two sampled residents (Resident #3 and #10) out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's Charting and Documentation Policy Revised July 2017 showed:
-The following information is to be documented in the resident medical record:
--Objective observations.
--Changes in the resident's condition.
--Events, incidents or accidents involving the resident.
-Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.
Review of the facility's Wounds Policy revised June 2021 showed a Weekly Skin Integrity Review form for staff to complete. Options included skin intact, bruises, rash, blisters, redness, skin tear with directions for staff to provide additional comments on the back of the form.
Review of the facility's Wound and Skin Care Protocols and Procedures dated 6/2021, showed the purpose was to promote a systematic approach and monitoring process for the care of residents with existing wounds and those who are at risk for skin breakdown., to prevent pressure sore (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) formation by identifying residents who are at risk and developing appropriate interventions, and to promote healing of pressure injuries in an efficient and timely manner. The Policy showed:
-All residents will be assessed by the charge nurse for risk of skin breakdown on admission, re-admission, and with any major change in condition.
-The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention or treatment of impaired skin integrity /pressure sore injury.
-The Director of Nursing will be responsible for ensuring wound care protocols are initiated and followed for all residents needing wound treatment and have orders for protocol.
-The Director of Nursing will be responsible for reviewing weekly wound reports and assuring compliance with current standards of wound care practice.
1. Review of Resident #34's Face Sheet showed the resident was admitted on [DATE] with diagnoses including diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar ), chronic (a wound that does not heal in an orderly set of stages and in a predictable amount of time or wounds that do not heal within three months) pressure ulcer of the foot, heart failure, seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements), low iron, high blood pressure and history of stroke (damage to the brain from interruption of its blood supply).
Review of the resident's Wound Consult dated 2/15/23, showed the resident had a non-healing chronic foot wound due to osteomyelitis (inflammation of bone caused by infection, generally in the legs, arm, or spine) and diabetes.
Review of the resident's Braden Scale assessment dated [DATE], showed the resident scored 15 (a score of 15 to 18 showed mild risk of developing wounds/pressure sores).
Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/24/23, showed the resident:
-Was alert and oriented without memory loss.
-Was dependent on staff for bathing, dressing, toileting and transfers.
-Did not have wounds and used preventive cushions, mattresses and nutritional interventions to manage skin issues and prevent development of pressure sores.
Review of the resident's Care Plan dated 8/3/23, showed the resident had potential for skin impairment due to limited mobility and diabetes. Interventions showed nursing staff would:
-Encourage the resident to reposition and weight shift.
-Follow physician ordered treatments.
-See the Wound Consultant weekly.
-Provide cushion and mattress.
-Refer the resident to the dietician to evaluate the resident's nutritional status as needed.
-Monitor the resident's nutritional intake.
-Keep the resident's linen and clothing free from wrinkles.
-Inspect the resident's skin for changes daily.
-Educate the resident and family on wound prevention and care.
Review of the resident's Nursing Notes showed on 8/10/23 nursing staff notified the physician the resident had increased edema in his/her lower extremities. The resident's physician gave orders to discontinue Lasix ( a medication used to reduce excess fluid in the body) and to start a new order for Bumex 1 milligram (mg) daily for edema (fluid in the tissues).
Review of the resident's Physician's Telephone Order dated 9/3/23, showed a physician's order for Bumex, 1 mg twice daily and wrap the resident's left leg during the day.
Review of the resident's Physician's Notes showed on 9/3/23 the physician saw the resident for a routine follow up. The note did not show any current wound to the resident's lower left foot or heel.
Review of the resident's Nursing Notes showed on 10/4/23 the resident stated his/her left heel was hurting. The nurse performed a skin assessment and found on the resident's left heel was a bluish brown blister that had opened and measured 3.1 centimeters (cm) length by 1.4 cm width by 0.0 cm depth. The nurse cleaned the area and put a temporary dressing on it until the nurse practitioner could see it today. The resident was to wear a blue soft boot for offloading. The Wound Consultant visited the resident and assessed his/her left heel and noted measurement to the left heel of 2.5 cm length by 4.0 cm width by 0.0 cm depth with serosanguineous (drainage from a wound that appears red or pink), exudate ( a clear fluid is usually a pale amber color and a watery consistency that plays an essential role in the healing process) was noted. The Wound Consultant wrote an order for Clindamycin 300 milligrams (mg) every 8 hours for 10 days for a wound infection to the left heel, clean the wound with normal saline (a mixture of salt and water), apply silver alginate (a wound care dressing which consists of calcium alginate and silver particles, which absorbs wound exudate), apply an ABD pad (Army battle Dressing -ABD - an extra thick primary or secondary dressing designed to care for moderate to heavily draining wounds), cover with rolled gauze and change daily and as needed. Continue to monitor.
Review of the resident's Physician's Telephone Order (PTO) showed on 10/4/23 Clindomycin 300 mg every 8 hours for 10 days for wound infection.
Review of the resident's Care Plan updated 10/5/23, showed:
-A wound developed to the resident's left heel.
-The resident frequently rubbed his/her heel on the bed while lying in his/her bed and declines to float his/her heel when recommended.
-There was a new treatment order for treatment to his/her left heel and the wound consultant will see the resident weekly.
-10/26/23 new order for an antibiotic for 14 days related to left heel wound infection.
Review of the resident's Nursing Notes showed:
-10/11/23- The nurse documented the Wound Consultant visited the resident and assessed the resident's left heel wound. The wound showed a small amount of drainage with no odor. The wound measured 2.5 cm length by 2.0 cm width by 0.0 cm depth. The resident had slight pain during the treatment today. Continue to monitor.
-10/18/23-The Wound Consultant visited the resident and assessed the resident's left heel wound. There was a small amount of serous exudate drainage without odor noted. There was slough (dead skin) on the wound bed. The wound measured 2.8 cm length by 2.0 cm width by 0.0 depth. Orders showed staff would continue to monitor, continue current treatment.
-10/26/23-The Wound Consultant visited the resident who assessed the resident's left heel. The wound had a medium amount of drainage with a slight odor which was tender to touch. The wound bed was yellow in color and wound edges were wet. The wound measured 2.0 cm length by 3.0 cm width by 0.0 depth. Orders showed staff would continue the current treatment and start the resident on Levaquin 500 mg daily for 14 days for infection. Documentation showed the resident wore a blue boot on his/her left foot to keep this/her left foot elevated.
Review of the resident's Treatment Administration Record (TAR) showed physician's orders for his/her left heel wound, to-clean the wound with normal saline, apply silver alginate, apply an ABD pad and cover with rolled gauze daily and as needed (10/4/23). The TAR showed:
-Nursing staff completed the treatment as ordered every day except on 10/8/23, 10/16/23 through 10/18/23, 10/20/23 through 10/22/23 and 10/28/23 through 10/30/23 (10 days treatments were not administered). There was no documentation showing why there were no treatments provided.
Review of the resident's POS dated [DATE], showed physician's orders to clean the resident's left heel with normal saline, then apply silver alginate, apply an ABD pad then cover with rolled gauze, change daily and as needed (10/4/23). There was also an order for Levaquin 500 mg daily for 14 days for wound infection (ordered on 10/26/23).
Review of the resident's Nursing Notes showed:
-11/1/23-The Wound Consultant visited the resident and assessed his/her left heel wound. The wound bed continued to be wet with a small amount of drainage noted and was tender to touch. The wound measured 1.5 cm length by 3.5 cm width by 0.1 cm depth. There was some improvement at this time. -The resident remained on an antibiotic. The Wound Consultant wrote a note to continue the antibiotic for another week (the resident had no side effects noted), continue the current treatment orders and keep the resident's leg elevated as much as possible. Continue to monitor.
-11/8/23 - The Wound Consultant visited the resident and assessed his/her left heel wound. The wound had a moderate amount of drainage, and appeared to be improving. There was no odor and the wound bed was tender to touch. The wound measured 2.0 cm length by 3.3 cm width by 0.1 cm depth. The Wound Consultant wrote orders to continue with the current treatment orders and documented the resident continued on an antibiotic for wound infection (the resident did not complain of side effects from the antibiotic) and continue to monitor.
-11/9/23- Showed the nursing staff gave the resident the last dose of antibiotic for his/her wound infection. Continue to monitor.
Review of the resident's TAR dated November 2023, showed physician's orders for his/her left heel wound to clean it with normal saline, apply silver alginate, apply an ABD pad and cover with rolled gauze daily and as needed (10/4/23). The TAR showed:
-Nursing staff documented they completed the resident's wound treatments on 11/1/23, 11/5/23, 11/6/23, 11/11/23 and 11/13/23. All dates in between the dates documented showed no documentation showing the treatments were administered (daily documentation was left blank) with no documentation showing why the treatment was not given.
Observation and interview on 11/13/23 at 9:56 A.M., showed the resident was sitting in his/her wheelchair in his/her room. He/She was wearing a blue boot on his/her left foot and had a right below the knee amputation. The resident said:
-The nursing staff treated him/her with dignity and respect and provided good care.
-Nursing staff had to help him/her with bathing and toileting primarily and wound care
-He/she has a blister on his/her left heel.
-When Licensed Practical Nurse (LPN) B was working, his/her wound treatment was completed, but when LPN B was not working, his/her wound treatment does not get done.
-His/her wound treatment was supposed to occur daily, but his/her last wound care treatment was last Thursday.
-He/she ad not had not yet received his/her wound treatment today, but LPN B was here so it will probably be completed.
-LPN B worked Tuesday, Wednesday and Thursdays and the Wound Consultant came in on Wednesdays to assess his/her wound.
-He/she was concerned about not receiving his/her wound care treatments daily, because he/she has had a wound infection and it has taken so long for his/her wound to heal.
Observation and interview on 11/14/23 at 8:39 AM, showed the resident was sitting on the side of his/her bed eating breakfast. His/Her left foot was wrapped with a thick, white gauze with a yellow sock over his/her left foot. The resident said that LPN B came in and completed the treatment to his/her left foot about an hour after the interview yesterday.
Observation and interview on 11/15/23 at 2:24 P.M., showed the resident was laying down in bed with his/her left leg and foot elevated. There was no dressing on his/her foot. The Wound Consultant was in the room with the resident, measuring his/her wound. The resident's heel wound was the size of a half dollar ,but oblong in shape. The edges of the wound were defined and there was no drainage or odor. There was some red areas around the edges of the wound and the wound bed was white. The Wound Nurse Consultant said:
-The resident had osteomyelitis and he/she had been working on the resident's wounds for over a year.
-They had healed this wound ,but it reopened and became infected so they started an antibiotic.
-The resident had recently finished the antibiotic and he/she was not going to start it again because the wound looked good (and there were no odors or signs of infection).
-He/She saw some granulation (the development of new tissue and blood vessels in a wound during the healing process) of the wound and it is looking better than it did last week.
-Due to the resident's osteomyelitis and edema in the resident's leg and foot, it was slow to heal, but was healing.
-He/She identified the wound as a chronic diabetic ulcer resulting from osteomyelitis and edema.
-He/She was waiting for lab work to come back and would not change the resident's wound care treatment at this time.
-He/She expected the nursing staff was completing the resident's wound care treatments daily in order for his/her wound to heal.
Observation on 11/15/23 at 2:30 A.M., showed LPN B came into the resident's room, sanitized his/her hands and brought in a tray containing wound care supplies and placed it on a towel that was on the resident's tray table. He/She gloved, and began to clean the resident's wound with normal saline on a clean gauze. He/She then de-gloved and discarded the gloves and gauze then washed his/her hands. He/she re-gloved, cut and applied silver alginate to the wound bed, then placed the ABD pad on top and wrapped it with sterile gauze. He/She then taped the gauze and dated it. He/She then de-gloved and washed his/her hands. At 2:47 P.M., LPN B said:
-He/she used to be the wound nurse and completed all of the wound care on all residents.
-He/she was no longer the wound nurse (as of two months ago) and now all of the nurses were responsible for completing wound care.
-He/she still rounded with the Wound Care Consultant on Wednesdays and documented in the nursing notes the wound assessment and measurements.
-When she was the wound care nurse, she would provide the wound care documentation to the Director of Nursing (DON) and the DON would enter the wound assessment documentation into the computer system for wound reporting.
-He/she did not know who entered the information into the computer system now, but the weekly documentation of the wound assessment he/she continued to document in the resident's nursing notes.
-He/she only worked three days weekly on Tuesday, Wednesday and Thursday.
-All of the nurses were supposed to document the wound care treatments in the residents TAR.
-Not all of the nurses completed the residents wound care, but they were supposed to because the resident's wound care was supposed to be completed daily.
-He/she noticed that the nurses had not been documenting on the TAR when/if they completed the resident's wound care.
-If the nurses did not complete the resident's wound care they were still supposed to document on the TAR and show why the wound care was not completed.
-He/she did not know who the wound care nurse in the facility was now, but all of the nurses were supposed to complete wound care.
-He/she said sometimes he/she got behind on completing the wound care paperwork because he/she was usually on the floor assisting the nursing staff with cares.
During an interview on 11/17/23 at 11:46 A.M. the Director of Nursing (DON) said:
-He/she was the interim DON as of 11/13/23.
-All wound care physician's treatment orders should be followed.
-He/she would expect the wound treatment documentation to be in the TAR, additional notes can be made on the back of the TAR or in the Nurses Notes, both types of documentation was acceptable.
-They did not have a designated wound care nurse at this time.
-Currently it was the nurse on duty's responsibility to complete the wound care treatment on resident's with wound care orders.
-Any nurse can complete wound care treatments, if the treatment falls on their shift they should do it.
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** 5. Review of Resident #30's Face Sheet showed he/she was readmitted to the facility on [DATE] with the following diagnoses:
-Ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #30's Face Sheet showed he/she was readmitted to the facility on [DATE] with the following diagnoses:
-Acute and chronic respiratory failure (caused when the respiratory system cannot adequately provide oxygen to the body) with hypoxia (not enough oxygen in the blood).
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation) with (acute) exacerbation.
Review of the resident's care plan dated 9/1/23 showed:
-The resident required oxygen therapy by nasal cannula pro re nata (PRN - as needed) and nebulizer treatments.
-Oxygen tubing to be changed per protocol.
-Humidification to be provided per protocol.
Review of the resident's POS dated September 2023 showed:
-Change oxygen tubing weekly on Sundays dated 8/18/23.
-Rinse oxygen foam filter with water, squeeze out excess water and return to concentrator, weekly on Sundays dated 8/18/23.
-Oxygen saturation every shift, notify physician if less than 90% dated 8/18/23.
-Oxygen at 2 LPM per nasal cannula as needed, may titrate (adjust) to keep oxygen saturation above 90% dated 8/18/23.
Review of the resident's September 2023 MAR/TAR showed:
-Change oxygen tubing weekly on Sundays dated 8/18/23. No documentation by facility staff this was completed four out of four opportunities.
-Rinse oxygen foam filter with water, squeeze out excess water and return to concentrator, weekly on Sundays dated 8/18/23. No documentation by facility staff this was completed two out of four opportunities.
-Oxygen saturation every shift, notify physician if less than 90% dated 8/18/23. No documentation by facility staff this was completed 57 out of 60 opportunities.
-Oxygen at 2 LPM per nasal cannula PRN, may titrate to keep oxygen saturation above 90%, dated 8/18/23. Staff documented oxygen applied four times with no documentation as to why or the resident's oxygen saturation levels.
Review of the resident's Significant Change MDS dated [DATE] showed he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 0 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation, and ability to register and recall new information. These items are crucial factors in care planning decisions) indicating the resident was cognitively intact.
Review of the resident's POS dated October 2023 showed:
-Change oxygen tubing weekly on Sundays dated 8/18/23.
-Rinse oxygen foam filter with water, squeeze out excess water and return concentrator, weekly on Sundays dated 8/18/23.
-Oxygen saturations each shift, notify physician if less than 90% dated 8/18/23.
-Oxygen at 2 LPM per NC PRN, may titrate to keep saturations above 90% dated 8/18/23.
Review of the resident's October 2023 MAR/TAR showed:
-Change oxygen tubing weekly on Sundays. No documentation by facility staff this was completed three out of five opportunities.
-Rinse oxygen foam filter with water squeeze out excess water and return to concentrator, weekly on Sundays. No documentation by facility staff this was completed three out of five opportunities.
-Oxygen saturation every shift, notify physician if less than 90% dated 8/18/23. No documentation by facility staff this was completed 40 out of 62 opportunities.
-Oxygen at 2 LPM per NC as needed, may titrate to keep saturations above 90%. Staff documented oxygen applied nine times with no documentation as to why or the resident's oxygen saturation levels.
Review of the resident's POS dated November 2023 showed:
-Change oxygen tubing weekly on Sundays dated 8/18/23.
-Rinse oxygen foam filter with water, squeeze out excess water and return to concentrator, weekly on Sundays dated 8/18/23.
-Oxygen saturation every shift, notify physician if less than 90% dated 8/18/23.
-Oxygen at 2 LPM per nasal cannula as needed, may titrate to keep oxygen saturation above 90% dated 8/18/23.
Review of the resident's November 2023 MAR/TAR showed:
-Change oxygen tubing weekly on Sundays. No documentation by facility staff this was completed two out of two opportunities.
-Rinse oxygen foam filter with water, squeeze out excess water and return to concentrator, weekly on Sundays. No documentation by facility staff this was completed two out of two opportunities.
-Oxygen saturations each shift, notify physician if less than 90%. No documentation by facility staff this was completed 20 out of 30 opportunities from 11/1/23 - 11/15/23.
-Oxygen at 2 LPM per NC PRN - may titrate to keep saturations above 90%. No documentation by facility staff the resident utilized his/her oxygen between 11/1/23 - 11/15/23.
--NOTE: The resident was observed using his/her supplemental oxygen multiple times during the survey.
Observation on 11/13/23 at 8:56 A.M., showed:
-The resident was receiving oxygen via an oxygen concentrator at 2.75 LPM.
-There was a wheelchair in the room with a portable oxygen tank hanging on the back, with the attached oxygen tubing and cannula lying on the seat uncovered, not in a bag or on a barrier, with no bag on the wheelchair for storage.
-A nebulizer mask lying on the nightstand, uncovered, not in a bag or on a barrier.
Observation on 11/14/23 at 9:06 A.M., showed:
-The resident was receiving oxygen via an oxygen concentrator.
-There was a wheelchair in the room with a portable oxygen tank hanging on the back, with the attached oxygen tubing and cannula lying on the seat uncovered, not in a bag or on a barrier, with no bag on the wheelchair for storage.
-A nebulizer mask lying on the nightstand, uncovered, not in a bag or on a barrier.
Observation on 11/15/23 at 8:46 A.M., showed:
-The resident was using an oxygen concentrator.
-There was a wheelchair in the room with a portable oxygen tank hanging on the back, with the attached oxygen tubing and cannula lying on the seat, under a jacket. The oxygen tubing and cannula were not stored in a bag or on a barrier, and no bag was on the wheelchair for storage.
-A nebulizer mask lying on the nightstand, uncovered, not in a bag or on a barrier.
Observation on 11/16/23 at 9:02 A.M., showed:
-The resident was not in his/her room. The wheelchair was not in the resident's room.
-The tubing/cannula attached to the oxygen concentrator was lying over the arm of the recliner not stored in a bag or on a barrier.
Observation on 11/16/23 at 9:21 A.M., showed:
-The resident was using an oxygen concentrator.
-There was a wheelchair in the room with a portable oxygen tank hanging on the back, with the attached oxygen tubing and cannula lying on the seat. The oxygen tubing and cannula were not stored in a bag or on a barrier, and no bag was on the wheelchair for storage.
Observation at 11/16/23 4:04 P.M., the resident asked Certified Nursing Assistant (CNA) A to fill the humidifier on his/her oxygen concentrator. CNA A went to the sink, filled the humidifier with tap water, and put it back on the machine.
During an interview on 11/17/23 at 10:50 A.M. CNA A said the resident usually sets the tubing on the seat of his/her wheelchair and recliner, not in the bags. CNA A said he/she placed the following in bags several weeks ago.
-The oxygen tank cannula/tubing inside a bag.
-The oxygen concentrator cannula/tubing.
-The resident's nebulizer mask.
-It is the nurse that checks oxygen levels on the concentrator.
During an interview on 11/17/23 at 10:35 A.M., the resident said he/she sets the tubing on the seat so he/she can grab it and go.
concentrator.
6. During an interview on 11/16/23 at 11:07 A.M., Certified Medication Technician (CMT) C said:
-He/she knew Resident #4 had an order for oxygen as needed but was not aware the resident ever used it.
-Nasal cannulas, oxygen masks, and nebulizers were to be stored in a bag when not in use to keep the supplies sanitary.
-He/she expected an order for nasal cannulas, oxygen masks, and nebulizers to be changed that included the frequency.
-He/she expected all residents that used oxygen to have an order for an oxygen humidifier as well.
-The night nurse was responsible for changing the humidifier canister and filling the water once a week.
-All nursing staff were responsible for ensuring oxygen supplies were stored properly when not in use.
-He/she expected non-nursing staff to notify nursing if they saw oxygen supplies stored improperly so the nursing staff could replace the item.
-Staff were to monitor the oxygen concentrator to ensure it was set at the correct LPM every time oxygen was in use.
-Nursing were to look at the oxygen concentrator every time they were in the room to ensure it was set for the correct LPM.
-Nebulizers were to be stored in a plastic bag or thrown away, even if rarely or never used.
During an interview on 11/16/23 at 11:16 A.M., Licensed Practical Nurse (LPN) B said:
-Resident #4 did not use oxygen.
-He/she was aware Resident #4 had an oxygen concentrator in his/her room.
-He/she believed Resident #4 should not have a concentrator in his/her room if oxygen was not ordered by the physician.
-He/she expected all oxygen supplies (nasal cannulas, nebulizers, oxygen masks) to be stored in a plastic bag when not in use.
-He/she expected an order to change the oxygen tubing and humidifier.
-He/she expected all oxygen supplies to be replaced weekly.
-He/she expected the filters on the oxygen concentrators to be cleaned weekly.
-He/she expected an order to fill the humidifier.
-Staff were expected to fill the oxygen humidifier with tap water but he/she didn't believe that was appropriate.
-All staff were responsible for ensuring oxygen supplies were stored correctly and not contaminated.
-Staff were to check to ensure oxygen supplies were stored correctly each time they entered the room.
-Staff were expected to verify the LPM of oxygen administration each time they checked a resident's oxygen saturation level, which was to be done at least once a shift.
-Staff were to store nebulizers in a plastic bag, even if the resident did not use it, and replace the nebulizer mask weekly.
During an interview on 11/17/23 at 10:50 A.M., CNA A said it is the nurse that checks the oxygen levels on the concentrator.
During an interview on 11/17/23 at 10:52 A.M., the Interim Director of Nursing (DON) said:
-Nursing checks to see if the levels are set correctly on the oxygen concentrators.
-The nurse should check to see if there is a titrate order, otherwise it should be what is ordered.
-Oxygen level settings are found in the POS.
-Oxygen saturations should be documented in the resident's treatment record.
-It is possible that residents may fiddle with their concentrator settings. He/She does not know if that has been an issue.
-Oxygen saturations are documented in the MAR/TAR and a few of them are missing.
During an interview on 11/17/23 at 12:06 P.M., the Interim DON said:
-He/she expected all nasal cannulas, nebulizer masks and mouthpieces, and oxygen masks to be stored in a dated bag when not in use.
-He/she expected an order to change the oxygen equipment and plastic bag weekly.
-He/she expected an order for the oxygen humidifiers to be checked and changed at the interval chosen by the physician.
-Oxygen humidifiers canisters were to be changed weekly or according to the facility policy.
-Oxygen humidifiers were to be filled with sterile or distilled water.
-He/she was unsure if tap water was appropriate for an oxygen humidifier.
-All care staff were responsible for ensuring oxygen supplies were stored properly when not in use.
-Staff were to visually check every time they entered a room to ensure oxygen supplies were stored properly.
-Staff were to verify each resident's oxygen concentrator was set to deliver the correct LPM each shift.
-He/she expected a nebulizer mask that wasn't be used to either be stored properly or removed.
Based on observation, interview, and record review, the facility failed to follow the physician's order for the amount of oxygen to be administered for three sampled residents (Resident #4, #26, and #1); to ensure orders were present for changing/cleaning oxygen supplies for four sampled residents (Resident #4, #26, #27 and #30); to ensure the humidifier was filled with sterile water for two sampled residents (Resident #4 and #26); to ensure oxygen administration and/or oxygen saturations (the amount of oxygen in the blood) were accurately documented for four sampled residents (Resident #4, #26, #1, and #30); and to properly store reusable oxygen equipment when not in use for five sampled residents (Resident #4, #26, #1, #27, and #30) out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's Oxygen Administration policy revised October 2010 showed:
-Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
-Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.
-Document the oxygen flow rate.
Review of the facility's Charting and Documentation policy revised July 2017 showed documentation in the resident's medical record should include any medications administered and treatments completed.
Review of the World Health Organization's (WHO) undated checklist, titled Care, Cleaning, and Disinfection of Oxygen Concentrators showed:
-Humidifiers were required to be washed, rinsed, and disinfected daily when used for the same person.
-Humidifiers could not be filled with tap water or bottled water. Distilled water that was stored at room temperature was also not to be used.
Review of Drugs.com last updated 11/16/23 showed Oxygen humidifier: Do not use tap water to fill the bottle. There are minerals and other things in tap water that could damage the equipment. Use distilled or sterile water when filling the bottle.
1. Review of Resident #4's admission Minimum Data Set (MDS-a federally mandated assessment tool used for care planning), dated 9/25/23 showed the resident was cognitively intact.
Review of the resident's current Physician's Orders Sheet (POS) showed the following physician's orders:
-On 9/13/23 for oxygen at 2 liters per minute (LPM) to be given as needed to keep oxygen saturation levels greater than 90% (normal range is 95-100%).
-On 9/13/23 for oxygen saturation to be monitored each shift.
-No order was present to change the nasal cannula (NC - tube in the nose).
-No orders were present related to the humidifier.
Review of the resident's care plan showed on 9/28/23 showed:
-The resident was at risk for shortness of air and use of oxygen therapy.
-Oxygen tubing was to be changed per facility protocol.
-The resident was to have a humidifier during his/her oxygen administration.
Review of the resident's Treatment Administration Record (TAR) dated November 2023 showed:
-Staff failed to document the resident's oxygen saturation for 17 out of 25 opportunities.
-The resident did not receive oxygen during the month.
Observation on 11/13/23 at 8:56 A.M. showed:
-The resident had an oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) in his/her room with a nasal cannula attached.
-No bag for storage of the nasal cannula.
-No date on the nasal cannula or attached humidifier.
-The humidifier was empty.
-The oxygen concentrator was set at 3 LPM.
During an interview on 11/13/23 at 8:56 A.M., the resident said:
-He/she used his/her oxygen every night.
-He/she put the oxygen on himself/herself.
-He/she wrapped up the tubing and stuck it in the handle of the machine so he/she wouldn't trip over it during the day.
-Staff had never told him/her how to store oxygen supplies.
-His/her oxygen was to run at 3 LPM.
Observation on 11/14/23 at 9:40 A.M. showed:
-The resident's nasal cannula, attached to the oxygen concentrator, was wrapped up and stuck in the handle of the machine uncovered.
-No bag was available for storage of oxygen supplies.
-No date on the nasal cannula or attached humidifier.
2. Review of Resident #26's Annual MDS, dated [DATE] showed the resident was cognitively intact.
Review of the resident's undated Physician's Orders showed the following physician's orders:
-On 7/6/23 for Duoneb (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) to be given via a nebulizer (a device for producing a fine spray of liquid to be inhaled) as needed for shortness of air.
-On 7/6/23 for staff to monitor the resident's oxygen saturation level every shift.
-On 7/6/23 for staff to administer oxygen at 1 to 2 LPM via nasal cannula to keep oxygen saturations greater than 90%.
-No order was present to change the nasal cannula.
-No orders were present related to the humidifier.
-No orders were present related to the cleaning, disinfecting, or replacement or the nebulizer mask.
Review of the resident's Care Plan showed staff entered a new problem on 9/25/23 stating:
-The resident had difficulty sleeping related to lack of oxygen.
-Staff were to provide humidification with oxygen administration.
-Staff were to change oxygen supplies per facility protocol.
Review of the resident's TAR, dated November 2023, showed:
-Staff documented the resident received Duoneb treatments five out of 13 days.
-Staff failed to document the resident's oxygen saturation level for 18 out of 25 opportunities.
-Staff documented the resident used oxygen twice during a 13 day period.
Observation on 11/13/23 at 8:56 A.M. showed:
-The resident had an oxygen concentrator in his/her room with a nasal cannula attached.
-No bag was available to store equipment.
-No date was present on the nasal cannula.
-The oxygen concentrator was running at 3 LPM.
During an interview on 11/14/23 at 12:36 P.M., the resident said:
-He/she performed the Duoneb treatment via the nebulizer approximately twice a week.
-A nurse had given him/her a dated plastic bag the night before but he/she was unsure of its purpose.
Observation on 11/14/23 at 12:36 P.M. showed:
-The resident was wearing his/her nasal cannula with the oxygen concentrator running at 3 LPM.
-The resident's nebulizer face mask was lying on the nightstand uncovered and with no barrier.
Observation on 11/15/23 at 10:45 A.M. showed:
-The resident was wearing his nasal cannula with the concentrator running at 3 LPM.
-The resident had a humidifier attached to his/her oxygen concentrator.
-A jug of room temperature distilled water on the resident's table.
During an interview on 11/15/23 at 10:45 A.M., the resident said:
-He/she had to buy his/her own water for the humidifier as staff would only use tap water.
-He/she did not feel comfortable inhaling tap water as he/she was aware bacteria was likely present in the city's water system.
Observation on 11/15/23 at 3:36 P.M. showed:
-The resident was wearing his/her nasal cannula with the concentrator running at 3 LPM.
-The oxygen humidifier was present and full.
3. Review of Resident #1's Quarterly MDS, dated [DATE], showed staff documented the resident:
-Had severe cognitive impairment.
-Was dependent on staff for dressing, sitting to lying, and rolling from side to side.
Review of the resident's undated Physician's Orders showed the following physician's orders:
-On 10/21/22 for oxygen tubing to be changed weekly.
-On 10/21/22 for oxygen saturation to be monitored each shift.
-On 10/21/22 for oxygen at 2 to 3 LPM as needed for shortness of breath.
Review of the resident' undated Care Plan showed staff entered a new problem on 4/20/23 stating:
-The resident was at risk for shortness of breath and required oxygen as needed.
-Staff were to change oxygen tubing per protocol.
Review of the resident's TAR, dated November 2023, showed:
-Staff did not document that the oxygen tubing was changed for 13 days.
-Staff failed to document the resident's oxygen saturation level for 18 out of 25 opportunities.
-Staff documented the resident used oxygen once during the month.
Observation on 11/13/23 at 8:56 A.M. showed:
-The resident was using his/her oxygen.
-The oxygen concentrator was set at 4 LPM.
Observation on 11/14/23 at 12:33 P.M. showed:
-The resident's nasal cannula was not dated.
-The nasal cannula was lying on the resident's bed, uncovered and undated.
Observation on 11/15/23 at 11:29 A.M. showed the resident's nasal cannula was coiled up and stuck in the handle of the concentrator without a barrier or cover.
Observation on 11/16/23 at 2:11 P.M. showed:
-The resident was lying in bed receiving oxygen.
-The oxygen concentrator was set at 4 LPM.
4. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff documented the resident was cognitively intact.
Review of the resident's Physician's Orders, dated November 2023, showed:
-The physician had entered an order for Albuterol (a bronchodilator) to be given via nebulizer as needed for congestion.
-The physician had entered an order for Ipratropium Bromide (a bronchodilator) to be given via nebulizer as needed for congestion.
-No orders were present related to the cleaning, disinfecting, or replacement or the nebulizer mask.
Review of the resident's Medication Administration Record (MAR) and TAR, both dated November 2023, showed neither medication was listed or documented as given.
Review of the resident's undated Care Plan showed congestion and/or shortness of air was not addressed.
Observation on 11/13/23 at 8:56 A.M. showed:
-The nebulizer mouthpiece was lying on the resident's bedside table under paperwork, uncovered and undated.
-The nebulizer mouthpiece was in direct contact with the bedside table.
Observation on 11/14/23 at 12:58 P.M. showed:
-The nebulizer mouthpiece was lying on the resident's bedside table under paperwork, uncovered and undated.
-The nebulizer mouthpiece was in direct contact with the bedside table.
During an interview on 11/14/23 at 12:58 P.M., the resident said:
-The resident administered his/her own nebulizer treatments when needed.
-Staff had given him/her a plastic bag but he/she did not know what it was for.
Observation on 11/15/23 at 1:32 P.M. showed the nebulizer mouthpiece was lying directly on the resident's nightstand with no barrier, uncovered, and undated.
During an interview on 1/15/23 at 1:40 P.M., the resident said:
-He/she only used the nebulizer when he/she needed it.
-He/she had not needed a nebulizer treatment for quite a while.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure three Nurse Aides (NA A, NA B, and NA D) out of four NAs hired were certified to become Certified Nursing Assistants (CNAs) within f...
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Based on interview and record review, the facility failed to ensure three Nurse Aides (NA A, NA B, and NA D) out of four NAs hired were certified to become Certified Nursing Assistants (CNAs) within four months of hire. The facility census was 41 residents.
Review of the facility's policy titled Nurse Aide Qualifications and Training Requirements dated August 2022 showed the facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise.
1. During an interview on 11/15/23 at 1:32 P.M. the Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said the facility had NAs, but was unsure of how long they had been working at the facility.
During an interview on 11/15/23 at 1:37 P.M. the Administrator said:
-He/she thought there was only one NA in the building, NA A.
-He/she needed to verify when NA A had started the classes.
Review of the facility's Hire Record Sheet dated 11/16/23 showed:
-NA A was hired on 4/20/23.
-NA B was hired on 12/14/22.
-NA D was hired on 5/29/23.
During an interview on 11/17/23 at 9:35 A.M. the Administrator said:
-NA A was enrolled in CNA classes, but had to re-enroll in the classes due to certain circumstances.
-He/she was aware that employees hired as NAs needed to be certified within four months of hire.
-He/she should have terminated NA A, but had not wanted to do that.
During an interview on 11/17/23 at 12:03 the Director of Nursing (DON) said he/she had not been involved in any parts of staffing yet.
During an interview on 11/17/23 at 1:12 P.M. the Administrator said:
-NA B and NA D were hired as NAs.
-NA B and NA D were still NAs at the time of the interview.
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** Based on observation, interview and record review, the facility failed to ensure accurate documentation and reconciliation of na...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accurate documentation and reconciliation of narcotic medications for three sampled residents (Residents #30, #23 and #141) out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's Medication Administration Policy, last revised April 2019 showed:
-The Director of Nursing Services (DON) supervises and directs all personnel who administer medications and/or have related functions.
-Medications are administered in accordance with prescriber orders, including any required time frame.
-The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
-As required or indicated for a medication, the individual administering the medication records in the resident's medical record:
--The date and time the medication was administered.
--The dosage.
--The signature and title of the person administering the drug.
Review of the facility's Controlled Substances Policy revised November 2022 showed:
-An individual resident controlled substance record is made for each resident who will be receiving a controlled substance. This record contains:
--Name of the resident.
--Name and strength of the medication.
-The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following:
--Records of personnel access and usage.
--Medication administration records.
1. Review of Resident #30's Face Sheet showed he/she was last admitted to the facility on [DATE] with diagnosis of other specified arthritis-multiple sites, unilateral primary osteoarthritis (a degenerative disease of the bones and joints)-right hip, and cervicalgia (neck pain).
Review of the resident's 9/19/23 Minimum Data Set (MDS -a federally mandated assessment tool to be completed by facility staff for care planning) showed:
-He/she was cognitively intact.
-He/she had pain present and frequently in pain.
-He/she received as needed pain medication.
Review of the resident's September 2023 Physician's Order Sheet (POS) showed Norco (a narcotic pain medication) 10/325 milligrams (mg), take one tablet by mouth every six hours as needed for pain dated 8/18/23.
Review of the resident's Norco 10/325 mg Narcotic Count Log for September 2023 showed Norco 10/325 mg removed from the narcotic count log 55 times between 9/2/23 - 9/30/23.
Review of the resident's September 2023 Medication Administration Record/Treatment Administration Record (MAR/TAR) showed:
-Norco 10/325 mg, take one tablet by mouth every six hours as needed for pain documented a administered nine times between 9/1/23 - 9/30/23.
--NOTE: 55 tablets were removed from the Narcotic Count Log, leaving 46 tablets unaccounted for.
Review of the resident's October 2023 POS showed Norco 10/325 mg, take one tablet by mouth every six hours as needed for pain dated 8/18/23.
Review of the resident's October 2023 Narcotic Count Log for Norco 10/325 mg showed 78 tablets were documented as removed between 10/1/23 and 10/31/23.
Review of the resident's October 2023 MAR/TAR showed:
-Norco 10/325 mg, one tablet by mouth every six hours for pain, not to exceed 3 grams/24 hours, dated 8/18/23.
-15 tablets were documented as administered.
--NOTE: 78 tablets were documented as removed from the Narcotic Count Log, leaving 63 tablets unaccounted for.
Review of the resident's November, 2023 Physician's Order Sheet showed Norco 10/325 mg, 1 tab by mouth every 6 hours as needed for pain, not to exceed 3 grams/24 hours, ordered 8/18/23.
Review of the resident's November 2023 Narcotic Count Log for Norco 10/325 mg showed 34 tablets were documented as removed between 11/1/23 and 11/16/23.
Review of the resident's November 2023 MAR showed:
-Norco 10/325 mg, 1 tab by mouth every 6 hours as needed for pain, not to exceed 3 grams every 24 hours, dated 8/18/23.
-10 doses of Norco 10/325 mg were documented as administered.
--NOTE: 34 tablets were documented as removed from the Narcotic Count Log, leaving 24 tablets unaccounted for.
2. Review of Resident #23's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses:
-Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) with diabetic autonomic polyneuropathy (a common form of neuropathy in patients with DM II characterized by dysfunction due to impairment of peripheral autonomic nerves).
-Hereditary (genetically transmitted) and idiopathic (arising spontaneously) neuropathy (nerve pain), unspecified.
Review of the resident's discharge assessment MDS dated [DATE] showed:
-The resident experienced pain.
-The resident was taking a Pro Re Nata (PRN) pain medication.
Review of the resident's October 2023 POS showed an order for Hydrocodone and Acetaminophen (Norco- an opioid used to treat pain) 5/325 mg, give one tablet by mouth every four hours as needed for pain dated 8/30/23.
Review of the resident's Norco 5/325 mg narcotic sheet dated from 10/18/23 to 10/31/23 showed nine tablets were documented as removed.
Review of the resident's October 2023 MAR showed the resident received a dose of Norco 5/325 mg twice, one dose on 10/1/23 and the other on 10/5/23.
--Note: Nine tablets were removed between 10/18/23 - 10/31/23, leaving nine tablets unaccounted for.
Review of the resident's November 2023 POS showed an order Norco 5/325 mg, give one tablet by mouth every four hours as needed for pain dated 8/30/23.
Review of the resident's Norco 5/325 mg Narcotic Sheet dated from 11/1/23-11/15/23 showed 21 tablets were documented as removed.
Review of the resident's November 2023 MAR through 11/15/23 showed:
-The resident received a dose of Norco 5/325 mg five times.
--NOTE: 21 tablets were removed between 11/1/23 - 11/15/23, leaving 16 tablets unaccounted for.
3. Review of Resident #141's Face Sheet showed the resident was admitted on [DATE], with diagnoses including leg and knee fracture, obesity (excessive body weight), anxiety, low iron, and asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe).
Review of the resident's admission MDS dated [DATE], showed the resident:
-Was alert and oriented without memory problems.
-Needed assistance with bathing, dressing toileting and transferring.
-Used a wheelchair for mobility.
-Had limitations on one side of his/her lower body.
-Experienced pain.
Review of the resident's POS dated November 2023, showed physician's orders for Norco 5/325 mg every 4 hours as needed for pain (ordered on 10/20/23).
Review of the resident's Controlled Medication Record Sheet showed a physician's order for Norco 5/325 mg every four hours for pain (10/20/23). The controlled record showed:
-On 10/22/23, the record showed 40 pills were dispensed on the medication card.
-On 11/9/23, one pill was dispensed with 39 pills left.
Review of the resident's Nursing MAR dated 11/2023, showed a physician's order for Norco 5/325 mg every four hours as needed for pain (10/20/23). Documentation showed there was no documentation showing any Norco was administered to the resident (it did not show at least one medication was dispensed on 11/9/23).
Observation on 11/16/23 at 10:09 A.M., showed the resident's medication card showed an order for Norco 5/325 mg every four hours as needed for pain (ordered 10/20/23). The card showed a total of 40 pills were dispensed onto the card. The card showed there were 39 pills left on the card that were not punched out. Licensed Practical Nurse (LPN) B said:
-The resident was no longer in the facility because he/she went to the hospital.
-They had just completed the narcotic card count today and the resident's card was in the medication cart.
-If the narcotic is dispensed and documented on the controlled count record, it should be documented on the nursing MAR also.
4. During an interview on 11/16/23 at 3:58 P.M. Registered Nurse (RN) A said:
-When a resident needs a narcotic then the nurse should document when the medication was given on the nurse MAR and the narcotic book.
-He/she was unsure if there was a specific facility policy related to narcotic documentation.
-He/she was aware that the documentation was not being completed on the nurse MARs.
During an interview on 11/17/23 at 10:52 A.M., the Interim DON said:
-The narcotics MAR and the control sheet (narcotic book) should match.
-If a narcotic is removed from the narcotic card, it should be documented on the narcotic control sheet and on the MAR.
-He/she just recently became the Interim DON and is unsure who, if anyone, audits to ensure the Narcotic Control Log and the resident's MAR/TAR match.
During an interview on 11/17/23 at 11:52 A.M. the Interim DON said:
-He/she would expect the nurses to document on the narcotic sheet and the nurse MAR when a narcotic is pulled and given to a resident.
-He/she thought an in-service was needed due to the lack of documentation on the nurse MAR compared to the narcotic book documentation.
-He/she thought it was ultimately the DON's responsibility to ensure the correct documentation was being done.
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** 3. Review of Resident #30's Face Sheet showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #30's Face Sheet showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:
-Acute and chronic respiratory failure (caused when the respiratory system cannot adequately provide oxygen to the body) with hypoxia (not enough oxygen in the blood).
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation) with (acute) exacerbation.
Review of resident's medical record from 3/8/23 to current showed no documentation of a facility assessment to determine if the resident was safe to administer and/or store medications at his/her bedside.
Review of the resident's Significant Change MDS dated [DATE] showed he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 0 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation, and ability to register and recall new information. These items are crucial factors in care planning decisions) indicating the resident was cognitively intact.
Review of the resident's Care Plan dated 9/19/23 showed:
-He/she uses nebulizer treatments.
-Give nebulizer treatments as ordered.
-No documentation to self-administer medication or to keep medication at bedside.
Review of the resident's November 2023 Physician Order Sheet (POS) showed:
-Flonase 50 microgram (mcg)/activation, 1 spray each nostril twice a day for Allergic Rhinitis, dated 8/18/23.
-Duoneb, 1 vial by nebulizer four times a day dated 10/13/23.
--No orders to keep the medication at bedside or for the resident to self-administer the medication.
Review of the resident's November 2023 MAR showed:
-Flonase 50 mcg/activation, 1 spray each nostril twice a day for Allergic Rhinitis, dated 8/18/23.
-Duoneb, 1 vial by nebulizer four times a day dated 10/13/23.
--The order did not include instructions to leave at bedside or for the resident to self-administer the medications.
Observation on 11/13/23 at 8:56 A.M., of the resident's room showed Flonase and Duoneb vials on the resident's bedside table.
During an interview on 11/13/23 at 9:00 A.M., the resident said:
-He/she keeps his/her respiratory medications, Flonase and Duoneb vials, in his/her room.
-He/she self-administers those medications.
Observation on 11/14/23 at 9:07 A.M. of the resident's room showed a bottle of Flonase on the resident's card table next to his/her plants.
During an interview on 11/14/23 at 9:46 A.M. the resident said:
-The Interim Director of Nursing (DON) came to his/her room last night and removed all of his/her Duoneb vials and a bottle of Flonase.
-He/she still had one bottle of Flonase in his/her room that was not removed last night.
-He/she was told the medication had to be removed from his/her room because State was in the building.
-He/she was allowed to keep the medication in his/her room for years and had always medicated himself/herself until last night.
Observation on 11/15/23 8:46 A.M. of the resident's room showed a bottle of Flonase nasal spray on the resident's card table next to his/her plants.
4. Review of Resident #3's Face Sheet showed resident was readmitted to the facility on [DATE].
Review of the resident's Care Plan dated 12/29/21 and last revised on 1/5/23 showed:
-He/she was at risk for pain.
-Staff will coordinate with his/her physician to manage pain medication to control his/her pain.
-No documentation the resident was able to self-administer medication or to leave medication at bedside.
Review of the resident's medical record from 1/5/23 to current showed:
-No documentation of a physician's order to keep medication at bedside.
-No documentation of a facility assessment to determine if the resident was safe to administer and/or store medications at his/her bedside.
Review of the resident's Significant Change MDS dated [DATE] showed:
-He/she scored 10 out of 15 on the BIMS indicating the resident was moderately cognitively impaired.
-He/she did not have pain and did not receive scheduled or as needed pain medication.
Review of the resident's November 2023 POS showed:
-Arthritis or commercial brand cream, twice daily to affected areas for arthritis pain, dated 5/4/23.
-No orders for Arthritis medication to be stored in resident's room or for the resident to self-administer the medication.
Review of the resident's November 2023 Treatment Administration Record (TAR) showed:
-Arthritis cream or commercial brand, twice daily to affected areas for arthritis pain. Dated 5/4/23.
-No orders for Arthritis medication to be stored in resident's room or for the resident to self administer the medication.
Observation on 11/13/2023 at 8:55 A.M., of the resident's room showed a tube of Arthritis medication on his/her bedside table.
Observation on 11/14/23 at 9:45 A.M., of the resident's room showed a tube of Arthritis medication on his/her bedside table.
Observation on 11/15/23 at 8:45 A.M., of the resident's room showed a tube of Arthritis medication on his/her bedside table.
5. During an interview on 11/15/23 at 3:30 P.M., the MDS Coordinator said:
-A resident would need a physician's order to have a medication at his/her bedside.
-No residents should have medications at the bedside without a physician's order.
-The resident would also need to be assessed to ensure they are able to administer the medication correctly and at the correct times.
-The assessments should be in the resident's medical records.
-He/she did not find a physician's order or an assessment for Residents #30 and #3 to have medications at bedside and/or to self administer medications.
During an interview on 11/15/23 at 3:45 P.M., the MDS Coordinator said:
-Staff were to ensure there was a physician's order and an assessment for self-administration of medications before any resident was allowed to keep medications in his/her room.
-There was no order for any of the residents to self-administer medications at this time so no residents were to have medications in their room.
During an interview on 11/16/23 at 11:16 A.M., LPN B said:
-Residents were allowed to keep medications in their room if they had a physician's order to do so.
-Once a physician's order had been entered, staff were required to do an assessment to ensure the resident could store the medication safely.
-He/she was aware Resident #26 had multiple vials of Duoneb in his/her room.
-He/she was aware an order should have been obtained for Resident #26 to keep medications in his/her room.
-Any medication that is stored in a resident room was to be stored in a bag in a drawer.
-None of the residents' nightstand drawers locked.
-Lock boxes were available if requested.
-He/she was not aware of any residents with a lock box containing medications.
-Medication and treatment carts were to always be locked when unattended.
During an interview on 11/17/23 at 10:52 A.M., the Interim DON said:
-A resident would need a physician's order to have a medication at his/her bedside.
-No residents should have medications at the bedside without a physician's order.
-The resident would also need to be assessed to ensure they are able to administer the medication correctly and at the correct times.
-The assessments should be in the resident's medical records.
-He/She was not sure who was responsible to audit to make sure the resident has physician's orders to keep medications at bedside and/or to ensure the resident's were assessed for the ability to self-administer medications.
During an interview on 11/17/23 at 12:06 P.M., the Director of Nursing (DON) said:
-Residents were allowed to keep medications in their room if an assessment for safety of administration had been performed and a physician's order had been obtained.
-He/she expected medication stored in resident rooms to be stored according to the facility's policy.
-He/she expected medications kept in resident rooms to be stored in a way in which other residents did not have access.
-Medication and treatment carts were to be locked when not attended.
-He/she expected all staff, including non-nursing staff, to lock a cart if they saw it unlocked.
Based on observation, interview, and record review, the facility failed to ensure the treatment and medication carts remained locked when not in use and not within eyesight; to ensure medications kept in resident rooms were stored in a locked compartment for three sampled residents (Resident #26, #3, and #30); and to ensure residents had physician orders and were assessed to keep medications at bedside and to safely self-administer medications left at the bedside for two sampled residents (Residents #3 and #30) out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's Administering Medications Policy revised April 2019 showed:
-Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.
-The director of nursing services supervises and directs all personnel who administer medications have related functions.
-Medications are administered in accordance with prescriber orders, including any time frame.
-Resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care team, has determined that they have the decision-making capacity to do so safely.
Review of the facility's policy, dated November 2020, titled Medication Storage showed:
-Drugs used in the facility were to be stored in locked compartments.
-Compartments containing drugs were to be locked when not in use.
-Unlocked medication carts were not to be left unattended.
-Residents were allowed to self-administer medications only if the physician and facility team believed the resident was able to do so safely.
1. Observation on 11/13/23 at 8:53 A.M. showed:
-A treatment cart near the 200 hall was unlocked with the keys in the lock.
-A medication cart near the 200 hall was unlocked.
-One staff member was at the desk, approximately 20 feet away, doing paperwork.
-One resident was in the area.
Observation on 11/16/23 at 10:19 A.M. showed the nurse's medication cart near the 200 hall was unlocked, with no staff within sight, and one resident was sitting in a wheelchair near the cart.
Observation on 11/16/23 at 10:23 A.M. showed:
-Registered Nurse (RN) A walked by the medication cart, took a key for the bathroom, and left the area without locking the cart.
-One resident remained approximately 15 feet from the cart in his/her wheelchair.
Observation on 11/16/23 at 10:26 A.M. showed:
-Licensed Practical Nurse (LPN) B approached the desk the unlocked medication cart was sitting against.
-LPN B talked with visitors but did not look at or lock the medication cart.
During an interview on 11/16/23 at 11:07 A.M., Certified Medication Technician (CMT) C said:
-Medication and treatment carts were to be locked at all times when unattended.
-He/she would lock any cart he/she saw was unlocked and unattended.
-He/she expected all staff, regardless of position, to look at medication and treatment carts as they passed by and, if found unlocked, to lock them.
2. Review of Resident #26's face sheet showed he/she was admitted with a diagnoses of Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]).
Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 6/15/23, showed:
-The resident was cognitively intact.
-The resident had difficulty breathing when lying flat, sitting up, or upon exertion.
Review of the resident's undated Care Plan showed staff documented:
-The resident did not participate in his own recovery.
-A sleep study was performed and the resident was to use oxygen at night but refused.
Review of the resident's Physician's Orders, dated November 2023, showed:
-The physician ordered Duoneb (a combination of bronchodilators used to treat and prevent symptoms such as wheezing and shortness of breath) one vial by nebulizer (a device used to administer medication to people in the form of a mist inhaled into the lungs) four times a day as needed.
-No documentation of a physician's order for the resident to self-administer medication.
Review of the resident's Medication Administration Record (MAR), dated November 2023, showed staff documented the resident had received five treatments in 13 days.
Observation on 11/14/23 at 12:36 P.M. showed two vials of Duoneb lying on the resident's nightstand.
During an interview on 11/14/23 at 12:36 P.M., the resident said:
-He/she was supposed to take the Duoneb treatment twice a day but only took the treatment approximately twice a week.
-Staff gave him/her the medication to administer himself/herself at his/her convenience.
During an interview on 11/15/23 at 3:22 P.M., the resident said:
-No one had ever told him/her that medication in his/her room were to be in a locked compartment.
-He/she did not have anywhere to lock up medication in his/her room.
-He/she had found additional vials of Duoneb in his/her drawer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the vegetables during the lunch meal on 11/13/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the vegetables during the lunch meal on 11/13/23 and the eggs during the breakfast meal on 11/16/23, were maintained at or close to a temperature of 120 ºF (degrees Fahrenheit) at the time of service. This practice potentially affected at least 13 residents who received room trays on the north side of the facility. The facility census was 41 residents.
1. Observation on 11/13/23 from 11:33 A.M. through 12:17 P.M., during the delivery of lunch meal room trays showed:
- At 11:33 A.M., the trays to be placed in the cart for the north hall, were loaded onto the cart.
- At 11:46 A.M., Dietary Aide (DA) A placed the cart for the North Hall just outside the Main Dining Room (MDR).
- At 11:55 A.M., 11:59 A.M., and 12:01 P.M., the cart for the north stayed in the same spot. The food cart stayed in the same spot for 16 minutes before Certified Nurse's Aide (CNA) D started to deliver room trays.
- Between 12:01 P.M., and 12:17 P.M., CNA D delivered room trays to residents in resident rooms 207, 211, 200 202,105, and 106, with one time in between where he/she had to go back to the kitchen to obtain butter, iced tea drinks, and sugar packets for a resident in 202.
- At 12:17 P.M., the foods on the test tray were checked for temperatures with CNA D as a witness. The temperature of the vegetables was 112 ºF.
During an interview on 11/13/23 at 12:24 P.M., CNA D said:
- He/she wished the facility staff had walkie-talkies (a small portable two-way radio set for receiving and sending messages) for better communication.
- He/she had not seen anyone from the dietary department come to hallways and check food temperatures.
- No one from the dietary department had informed him/her that that the food cart for the North Hall stayed in the same spot for 16 minutes.
During an interview on 11/13/23 at 12:34 P.M., Dietary [NAME] (DC) A said:
- He/she started to prepare the food trays after the residents get their drinks delivered to them.
- There was not any verbal communication with nursing staff to start delivering the room trays, when the cart goes out to the hallways.
During an interview on 11/13/23 at 1:43 P.M., the Dietary Manager (DM) said:
- A couple weeks ago when he/she was a cook, he/she would tell the nurse at the desk that the trays were ready to be served to the residents.
- That happened when he/she was a cook.
- Now that he/she was no longer a cook, he/she was not sure what happened to that method of communication.
2. Observations on 11/16/23, showed the following:
- From 8:07 A.M. through 8:14 A.M., Dietary Aide (DA) C prepared plates for delivery to the North Hall and placed the plates on the cart.
- At 8:14 A.M. DA C delivered cart to the area outside the dining room and resident room [ROOM NUMBER].
- No communication noticed between DA C and anyone from the nursing department to let them know the cart was ready for delivery.
- At 8:15 A.M., Licensed Practical Nurse (LPN) B, started delivering meals to residents on the North side.
- At 8:19 A.M., LPN B had to stop the delivery to spread butter and pour syrup on the resident's pancakes and LPN B did not leave that room until 8:21 A.M.
- At the end of the room tray delivery, LPN B informed the state surveyor, there were two trays left that residents did not want.
- At 8:25 A.M., with LPN B and the Administrator observing, the temperature of the eggs on the 1st tray was 105.2 ºF.
Record review of Resident #10's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 8/15/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15.
During an interview on 11/16/23 at 9:15 A.M., Resident #10, said the French fries were cold on Wednesday (the day before the observation) of the breakfast foods.
Record review of Resident #30's quarterly MDS dated [DATE], showed he/she was cognitively intact with a BIMS of 15 out of 15.
During an interview on 11/16/23 at 9:31 A.M., Resident #30 said he/she believed that his/her food was delivered to him/her cold about once or twice per week.
Record review of Resident #12's quarterly MDS dated [DATE], showed he/she had moderate cognitive impairment with a BIMS of 11 out of 15.
During an interview on 11/16/23 at 11:23 A.M., Resident #12 said:
-The food was watery, did not taste good, and was cold.
-The food was not palatable.
-The food delivery carts needed insulation. and
-Breakfast was delivered to him/her cold daily.
Record review of Resident #27's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 13 out of 15.
During an interview on 11/16/23 at 11:31 A.M., Resident #27 said the food was delivered to him/her cold.
During a phone interview on 11/17/232:05 P.M., the Consultant RD said:
- Cold food had not been an issue that he/she has seen.
- He/she had not heard the intercom communication between nursing and dietary in about 3 months.
- In the past, he/she used to hear a dietary person announce that the room tray cart was ready for delivery.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumonia-a bacteria that causes inflammation of the ...
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Based on interview and record review, the facility failed to ensure pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumonia-a bacteria that causes inflammation of the lungs) vaccinations were offered for three sampled residents (Resident #1, #14, and #9) out of 12 sampled residents. The facility census was 41 residents.
Review of the facility's policy, dated March 2022, titled Pneumococcal Vaccine showed:
-Staff were to assess each resident's vaccination status prior to admission or within five working days.
-Staff were to provide education on the benefits and side effects of the vaccination and the education was to be documented in the resident's medical record.
-If the resident or their representative refused the vaccine, appropriate information was to be documented by the staff in the resident's medical record, including the date of refusal.
1. Review of Resident #1's Face Sheet showed he/she was admitted with a diagnoses of Chronic Kidney Disease (CKD-a gradual loss of kidney function over time).
Review of the resident's undated Care Plan showed:
-Staff documented the resident was at risk for shortness of breath.
-Staff had documented the resident was no longer able to make his/her own decision and had enacted the resident's Durable Power of Attorney (DPOA).
-Staff documented the resident was at risk for infections due to his/her CKD.
Review of the resident's Informed Consent for Pneumococcal Vaccine, dated 10/9/20, showed:
-Staff had marked the resident and/or DPOA refused the vaccine.
-The only signature present was that of the facility staff nurse.
-Staff had not documented who refused the vaccine or when, nor obtained a signature of the person that declined the vaccine.
Review of the resident's Physician's Orders, dated August 2023, showed the physician ordered antibiotics for 10 days with a diagnoses of pneumonia.
During an interview on 11/16/23 at 3:22 P.M., the resident's DPOA said he/she had refused the vaccine for the resident approximately three weeks ago.
2. Review of Resident #14's face sheet showed he/she had a current diagnoses of pneumonia by an unspecified organism.
Review of the resident's undated Care Plan showed staff documented the resident was at risk for shortness of air and respiratory issues.
A request for a copy of the resident's Informed Consent for Pneumococcal Vaccine was made on 11/14/23 at 2:01 P.M. in writing to the Administrator and was not received at time of exit.
3. Review of Resident #9's face sheet showed he/she had been admitted with a diagnoses of Diabetes Mellitus Type 2 (a chronic condition that affects the way the body processes blood sugar [glucose]).
Review of the resident's Informed Consent for Pneumococcal Vaccine, dated 10/5/20, showed:
-Staff had marked that the resident and/or DPOA refused the vaccine.
-The only signature present was that of the facility staff nurse.
-Staff had not documented who refused the vaccine or when, nor obtained a signature of the person that declined the vaccine.
Review of the resident's Physician's Orders, dated September 2023, showed the physician ordered antibiotics on 9/8/23 with a diagnosis of pneumonia.
Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 10/5/23, showed:
-The resident was cognitively intact.
-Staff had offered the pneumonia vaccine and the resident had declined.
During an interview on 11/16/23 at 12:50 P.M., the resident said he/she had not been offered or refused the pneumonia vaccine.
4. During an interview on 11/15/23 at 10:07 A.M., the Administrator said:
-Staff were to document in a nurse's note in the resident's medical record when a vaccine was refused.
-Staff were to document who refused the vaccine, the date and time of the refusal, and the reason.
-Staff were not required to offer a vaccine again if it was initially declined.
During an interview on 11/16/23 at 11:16 A.M., Licensed Practical Nurse (LPN) B said:
-Any resident and/or the resident's DPOA that declined a vaccine was required to sign the declination form.
-If a resident's DPOA was not available to sign the declination form, he/she expected a note in the medical record indicating who refused it, if they refused in person or over the phone, the date and time, and the signature of the nurse.
-He/she expected staff to offer medically appropriate vaccines annually if previously refused.
During an interview on 11/16/23 at 2:40 P.M., the Administrator said:
-A facility nurse had called the family of each resident and the family had refused which was why the forms were marked as declined.
-He/she did not have any additional documentation regarding the declinations.
-He/she was unable to find the pneumonia vaccine paperwork for Resident #14.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure staffing was posted daily and accurately at the beginning of each shift including the total number and actual hours worked by licensed...
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Based on observation and interview, the facility failed to ensure staffing was posted daily and accurately at the beginning of each shift including the total number and actual hours worked by licensed care staff which could have the potential to affect some residents and visitors in the facility. The facility census was 41 residents.
1. Review of the facility's policy titled Posting Direct Care Daily Staffing Numbers dated August 2022 showed:
-The facility would post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.
-Within two hours of the beginning of each shift, the number of licensed nurses Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) and the number of unlicensed nursing personnel Certified Nursing Assistants (CNAs) and Nurse Aides (NAs) directly responsible for the care is posted in a prominent locations and is in a clear and readable format.
-Shift staffing information is recorded on a form and includes the following:
--The name of the facility.
--The current date (the date for which the information is posted).
--The resident census at the beginning of the shift.
--Twenty-four hour shift schedule operated by the facility.
--Type (RN, LPN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contracted staff).
--The actual time worked during that shift for each category and type of nursing staff.
--The total number of licensed and non-licensed nursing staff working for the posted shift.
--Within two hours of the beginning of each shift, the charge nurse or designee completes the form and posts the staffing information in the locations designated by the Administrator.
Observation on 11/13/23 at 9:59 A.M. showed:
-The posted staffing was dated 11/12/23.
NOTE: An updated staffing sheet was not posted anytime throughout the day while on site.
Observation on 11/15/23 at 10:47 A.M. showed no RN coverage in the building even though there was RN coverage for eight hours for that day.
Observation on 11/16/23 at 8:59 A.M. showed:
-The staffing sheet from 11/15/23 was still posted.
NOTE: An updated staffing sheet was not posted anytime throughout the day while on site.
During an interview on 11/16/23 at 1:52 A.M. CNA B said:
-The facility posts staffing in a book, on a white board, and at the front of the building near the entrance.
-He/she was unsure of who was responsible for posting the staffing sheets.
-The staffing sheet should include the amount of care staff that are scheduled in the building.
-The staffing sheet should be accurate and be posted daily.
During an interview on 11/16/23 at 3:57 P.M. RN A said:
-The charge nurse was responsible for posting the daily staffing sheets.
-The staffing sheet should include the date, census, and the amount of care staff scheduled in the building.
-The staffing sheet should be posted daily and be accurate.
Observation on 11/17/23 at 9:15 A.M. showed a staffing sheet had been posted, but was dated for 11/16/23.
During an interview on 11/17/23 at 9:35 A.M. the Administrator said:
-The night nurse was responsible for posting the staffing sheet.
-He/she expected this to be done daily and for the sheet to be accurate.
-He/she would expect the on-coming day nurse and/or Director of Nursing (DON) to ensure that the daily staffing sheet had been posted.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the dietary department failed to have recipes available to process the follow...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the dietary department failed to have recipes available to process the following foods into a pureed (to make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) form (peach crisp, chicken [NAME] pasta, and Italian Blend vegetables) potentially affecting three residents with pureed diets; and to provide a menu with a wider variety of choices for entrees, other than chicken, for the week 1 menu. This practice potentially affected all residents. The facility census was 41 residents.
1. Observation on 11/13/23 from 9:45 A.M. through 11:31 A.M., during the lunch meal preparation showed:
- At 9:47 A.M., Dietary [NAME] (DC) A made pureed peach crisp with no recipe book open.
- At 10:59 A.M., DC A made pureed vegetables with no recipe book open.
- At 11:08 A.M., DC A made the pureed chicken [NAME] dish, with no recipe book open.
During an interview on 11/13/23 at 1:38 P.M., the Dietary Manager (DM) said they have been using the fall menus for almost a month now but there were no recipes for pureed items so far and he/she would have to contact with the Administrator to obtain the recipes.
During an interview on 11/16/23 at 11:09 A.M., the Administrator said:
- The DM did not have access to the menus because he/she did not have a computer in his office.
- He/she could access the recipes by asking the Administrator to print the recipes off or by going to someone else in the facility with a computer.
During a phone interview on 11/17/23 at 2:05 P.M., the Consultant Registered Dietitian (RD) said:
- The dietary staff would have to go to a website entitled Dining RD and print off the menus.
- The DM did not have a computer in his/her office.
- The facility would have to contact Dining RD to send the menus through the mail.
2. Review of the Menu for week 1 of the Cycle, showed the following for the week (11/13/23 through 11/17/23) the survey took place:
- Chicken was the entrée for lunch on 11/12/23
- Chicken was the entrée for lunch on 11/12/23
- Chicken was the entrée for dinner on 11/15/23.
During an interview on 11/13/23, DC A said he/she had to make a change in the lunch menu for 11/13/23, from spaghetti with meat sauce to Chicken [NAME] pasta, because the dietary department ran out of sauce and meat for the menu for that day.
Record review of Resident #34's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 4/10/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15.
During an interview on 11/16/23 at 9:06 A.M., Resident #34, a resident said the facility has too much chicken on the menu.
Record review of Resident #10's quarterly MDS dated [DATE], showed he/she was cognitively intact with a BIMS of 14 out of 15.
During an interview on 11/16/23 at 9:15 A.M., Resident #10 said chicken was served too much.
Record review of Resident #30's quarterly MDS dated [DATE], showed he/she was cognitively intact with a BIMS of 15 out of 15.
During an interview on 11/16/23 at 9:31 A.M., Resident #30 said there was too much chicken on the menu and he/she wanted beef a little more often.
During an interview on 11/16/23 at 10:31 A.M., the Administrator said:
- He/she heard from the residents that there was too much chicken on the menu.
- The company allowed the facility to make changes within the menu as long as those changes have been approved by the RD.
- At that time (the time of the survey) the facility did not have always available substitutions.
Record review of Resident #12's quarterly MDS dated [DATE], showed he/she had moderate cognitive impairment with a BIMS of 11 out of 15.
During an interview on 11/16/23 at 11:23 A.M., Resident #12 said the facility did not seem to have a good variety of meals and there were too many chicken choices on the menu.
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, the facility failed to discard a head of lettuce which turned brown; to label containers with a white powdery substance with what was in that container; to remove g...
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Based on observation and interview, the facility failed to discard a head of lettuce which turned brown; to label containers with a white powdery substance with what was in that container; to remove grime from the floor under the two compartment sink close to the walk-in refrigerator; to remove dirt and debris from behind the six-burner stove; to maintain 3 cutting boards without numerous nicks and in an easily cleanable condition; to maintain one mitten without a damaged area; to date containers of leftovers in the reach-in refrigerator with the date they were placed in the refrigerator; to label containers in the reach-in refrigerator with what the item was; and to maintain the faucet of the two compartment sink in good repair. This practice potentially affected all 41 residents. The facility census was 41 residents.
1. Observations on 11/13/23 from 9:14 A.M. through 12:35 P.M., showed:
- One head of lettuce that was brown colored.
- One unlabeled container with a green cover on the food preparation table with a white powdery substance in it.
- One container of soup in the walk-in refrigerator, which was not labeled.
- Other containers in the reach-in refrigerator which included refried beans with no label of the date or the item, a container of burgers with no date or name of item, a container of vegetable soup with a date of 10/25/23 which was 19 days prior to the date (11/13/23) of the observation, a container of bar-b-cue sauce without a date or a label of what was in that container and a container of ham and beans with no date that that container was placed in the refrigerator.
- A buildup of dust and grime on the floor beneath the two compartment sink and behind the six-burner stove and convection oven.
- Three cutting boards with numerous nicks and grooves which were not easily cleanable.
- One mitten with a one-inch (in.) tear between the area where the thumb and the fingers were located.
-A continuous leak from the faucet at the two compartment sink.
- A light fixture over the food preparation table which illuminated intermittently.
During interviews on 11/13/23, the Dietary Manager (DM) said the following:
- At 10:06 A.M., the faucet has had a drip since July 2023, but the drip has gotten worse over the last few weeks.
- At 10:08 A.M., he/she expected dietary employees to label the containers with what was in them.
- At 10:10 A.M., He/she expected dietary employees to label the soup with the date the soup was placed in there.
- At 10:13 The vegetable soup should have been discarded,
- At 1:31 P.M., the dietary staff should get behind the stove and the two compartment sink at least once per week, but they have not been doing that consistently.
- At 1:33 P.M., Anyone who used the cutting boards was responsible for notifying him/her that new ones needed to be ordered.
- At 1:35 P.M., the dietary staff should notify him/her when the mittens were torn like that.
During an interview on 11/14/23 at 10:42 A.M., the DM said he/she was not sure how long the light fixture over the food preparation table has not been working.
During an interview on 11/14/23 at 10:43 A.M., the Maintenance Director said he/she did not know about the light fixture over the food preparation table not working.
2. Observation on 11/16/23 at 1:24 P.M., showed the same head of lettuce which was brown from the previous observation on 11/13/23.
During an interview on 11/16/23 at 1:26 P.M., Dietary [NAME] (DC) A said he/she did not check the lettuce for that week.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based interview and record review, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use pro...
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Based interview and record review, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 41 residents.
Review of the facility's policy, dated December 2016, titled Antibiotic Stewardship-Orders for Antibiotics showed:
-Appropriate indications for antibiotic use included a culture and sensitivity (C&S-a culture is a test to find germs (such as bacteria or a fungus) that can cause an infection; a sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) and having met the clinical definition of an active infection.
Review of the facility's policy, dated December 2016, titled Antibiotic Stewardship-Staff and Clinician Training and Roles showed the Director of Nursing (DON) was to review all clinical documentation supporting antibiotic orders.
1. Review of the facility's Infection Control Log, dated August 2023, showed:
-Staff listed the residents that had been given antibiotics.
-Staff listed the antibiotics used by each resident but did not list the amount or duration of the medication.
-No C&S testing had been performed for any of the residents.
-A spreadsheet titled Antibiotic Usage Surveillance Tool was blank.
Review of the facility's Infection Control Log, dated September 2023, showed:
-Staff listed the residents that had been given antibiotics.
-Staff listed the antibiotics used by each resident but did not list the amount or duration of the medication.
-No C&S testing had been performed for any of the residents.
-A spreadsheet titled Antibiotic Usage Surveillance Tool was blank.
Review of the facility's Infection Control Log, dated October 2023, showed:
-Staff listed the residents that had been given antibiotics.
-Staff listed the antibiotics used by each resident but did not list the amount or duration of the medication.
-No C&S testing had been performed for any of the residents.
-A spreadsheet titled Antibiotic Usage Surveillance Tool was blank.
During an interview on 11/15/23 at 11:10 A.M., the Regional Registered Nurse (RN) said:
-He/she was the facility's Infection Control Preventionist (ICP).
-He/she monitored antibiotics as much as he/she could but he/she had other work to do.
-He/she looked at the facility's antibiotic log sometimes, and sometimes he/she did not.
-The ICP was to log the antibiotic usage on the Antibiotic Usage Surveillance Tool.
-The physicians frequently did not order a c&s or any testing to verify the appropriate antibiotic was in use.
-The facility could not produce documentation of antibiotics used from May 2022 to November 2023.
-He/she expected the antibiotic use in the facility to be monitored.
-He/she was aware antibiotic use was not being monitored in the facility.
During an interview on 11/16/23 at 2:23 P.M., the Administrator said:
-He/she expected the ICP to monitor antibiotic use.
-He/she expected the ICP to follow the criteria for infections listed in the facility's policy.
During an interview on 11/17/23 at 12:06 P.M., the DON said:
-He/she expected the ICP to monitor antibiotic use for the facility.
-He/she expected the ICP to fill out the tracking forms for antibiotic use completely and accurately.
-He/she expected the facility's policies to be followed.
-He/she was not involved in the monitoring or tracking of the facility's antibiotic use; the ICP was responsible for that.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure an Infection Preventionist (IP) was designated and certified in infection prevention and control. The facility census was 41 residen...
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Based on interview and record review, the facility failed to ensure an Infection Preventionist (IP) was designated and certified in infection prevention and control. The facility census was 41 residents.
Review of the facility's undated policy titled Components of Infection Control showed the IP was to complete the required Center for Disease Control's (CDC) course on Infection Preventionist training.
1. During an interview on 11/13/23 at 8:59 A.M., the Administrator said:
-He/she had not completed the IP course.
-The facility did not have an IP as of 10/27/23.
-He/she had been tracking infections in the building until a new IP could be found.
-He/she had hired a new Director of Nursing (DON) as of 11/13/23.
During an interview on 11/15/23 at 10:07 A.M., the Administrator said:
-The DON had completed the CDC Infection Preventionist training.
-The Regional Registered Nurse (RN) oversaw the program but hadn't been running it.
-The Regional RN usually came in once a week but would come more often if needed.
Review of the Regional RN's IP training records, received 11/15/23 at 11:08 A.M., showed no certificate of completion.
During an interview on 11/15/23 at 11:10 A.M., the Regional RN said:
-He/she was in the facility at least once a week but sometimes twice.
-He/she was typically in the building for eight hours per visit.
-He/she took over the IP role 10/27/23.
-The DON had not been filling the role of IP for the facility.
-He/she tried to monitor infections and antibiotics as much as he/she could but he/she had other buildings to oversee.
-He/she may or may not look at the infection and antibiotic log when he/she was at the facility.
During an interview on 11/15/23 at 11:43 A.M., the Regional RN said he/she was aware antibiotic use was not being monitored.
During an interview on 11/15/23 at 2:18 P.M., the Regional RN said he/she could not find the certificate of completion for the IP course.
During an interview on 11/16/23 at 11:16 A.M., Licensed Practical Nurse (LPN) B said:
-He/she expected federal regulation for the IP to be followed.
-He/she expected someone in the building to monitor antibiotic use and infections.
During an interview on 11/16/23 at 2:23 P.M., the Administrator said:
-The DON was the IP.
-The DON had not been able to find his/her certificate of completion for the IP course but had reached out to the CDC for assistance.
-The Regional RN was the backup IP.
-The DON had started October 2023.
-The DON worked three to five days a week providing resident care.
-The DON did not spend part time working on infection control.
-He/she expected the IP to monitor antibiotic use and follow the facility's policy.
During an interview on 11/17/23 at 12:06, the DON said:
-He/she was unsure who the IP was for the facility.
-He/she expected the IP to monitor infection and antibiotic use in the facility.
-He/she expected the facility's policy and federal regulations to be followed.
At time of exit, no staff member had submitted a certification of completion for the CDC's Infection Preventionist course.
Apr 2023
1 deficiency
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to keep one card of Hydrocodone-Acetaminophen 5/325 mill...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to keep one card of Hydrocodone-Acetaminophen 5/325 milligrams (mg), (a narcotic pain medication used to treat severe pain) double locked at all times, resulting in one card of 30 tablets missing for one sampled resident (Resident #1) out of five sampled residents. The facility census was 44 residents.
Record review of the facility's Controlled Substances policy revised December 2012 showed:
-The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.
-Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises.
-The Director of Nursing Services will identify staff members who are authorized to handle controlled substances.
-Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record.
-Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents.
-All keys to controlled substance containers shall be on a single key ring that is different from any other keys.
-The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers.
-Unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container.
-Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.
-The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings.
-The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated.
1. Record review of Resident #1's Facility Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Stroke.
-Hip fracture.
-Ulna fracture-(a break in the thinnest, longest bone of the two bones in the lower arm).
Record review of the resident's Physician's Order Sheet (POS) dated 1/3/23 showed:
-He/she was prescribed Hydrocodone-Acetaminophen 5/325 mg, one tablet by mouth three times per day as needed for pain.
Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 1/9/23 showed he/she:
-Was not cognitively intact.
-Had moderate issues with mood including having little energy, feeling tired, having a poor appetite or overeating two to six days per week.
-Had no negative behaviors.
-Required extensive assistance of one staff member for bed mobility, transfers, toileting, and dressing.
-Was totally dependent on one staff member for locomotion on and off the unit.
-Required supervision of one staff member for eating and limited assistance of one staff member for personal hygiene.
-Received as needed pain medication on an as needed basis over the past five days.
-Received non-medication intervention for pain over the past five days.
Record review of the resident's Nursing Care Plan dated 1/18/23 showed:
-He/she had a potential for severe pain due to fractured bones.
-He/she was to stay as pain free as possible through the review period.
-Facility staff was to observe for pain, including non-verbal signs of pain and document hourly.
-Provide him/her with narcotic pain medication when he/she expresses discomfort.
-Assess him/her for the effectiveness of the pain medication.
-The facility staff was to provide him/her with non-medication comfort measures such as back rubs, lotion to his/her body, and warm sponge baths.
Record review of the pharmacy/facility consolidated delivery sheets dated 3/10/23 at 5:10 P.M., showed 30 Hydrocodone-Acetaminophen 5-325 mg tablets were delivered to the facility and received by Registered Nurse (RN) A.
Record review of the facility Controlled Substance Log dated 3/11/23 showed RN A created the log for 30 Hydrocodone-Acetaminophen 5-325 mg for Resident #1.
Record review of the facility Shift Verification of Controlled Substances Count showed on 3/18/23 at the 7:00 P.M., narcotic count it was discovered that one card of 30 Hydrocodone-Acetaminophen 5-325 mg tablets for the resident was not in the narcotic drawer and the Director of Nursing (DON) was notified.
Record review of the written statement of RN A dated 3/20/23 showed:
-His/her last shift to work was Thursday 3/16/23.
-He/she left Friday morning and counted narcotics with the DON.
-The narcotics count was correct at that time.
-He/she was then off work 3/17/23 through 3/19/23.
Record review of the facility's Report of Loss of Theft of Controlled Substances dated 3/21/23 at 10:56 A.M., showed:
-On 3/10/23, one card of 30 count Hydrocodone-Acetaminophen 5-325 mg tablets for the resident was delivered to the facility and signed for by the evening shift nurse RN A.
-On 3/18/23, the count sheet was accounted for, however, the card of medication was not accounted for.
-An extensive search was completed, all nurses and certified medication technicians were interviewed.
-The local police were contacted and a report was filed.
-At the time of the report, the medication remained missing.
Record review of the Voluntary Statement for the local police department prepared by the facility DON dated 3/23/23 showed:
-On the evening of March 18, 2023 at approximately 8:30 P.M., Licensed Practical Nurse (LPN) A called the DON to report the resident's card of Hydrocodone-Acetaminophen 5-325 mg, 30 tablets was found missing at shift change.
-The card was accounted for at the day shift narcotic count, but was missing at the night shift narcotic count.
-All nurses with access to the cart were interviewed and drug tested by urine sample through an outside vendor.
-All appropriate entities were notified.
Record review of the written statement from RN B written 3/21/23 showed:
-On Friday, 3/17/23 verify date at the day shift narcotic count for the 100/200 unit, just after having sent a resident out to the hospital, he/she believed there were 22 or 23 narcotic cards in the cart and it was believed the narcotic count was accurate at that point.
-He/she then went to work on schedules in his/her office, and left the facility at approximately 10:15 A.M.
Record review of the written statement from RN C dated 3/21/23 showed:
-On Saturday 3/18/23 at around 7:45 P.M., while counting with LPN A, it was discovered that the resident's card of Hydrocodone-Acetaminophen 5-325 mg was missing, but the sheet was inside the narcotic count book.
-The nurses looked in all the carts, medication room and could not find the card of 30 tablets.
-LPN A texted RN A who was also the Assistant Director of Nursing (ADON) and the DON with a screen shot of the narcotic sheet that was missing.
-RN A gave the okay to take the keys from LPN A and leave Resident #1's narcotics sheet in his/her ADON office so he/she could look at it on Monday.
-RN B also texted the Administrator to inform him/her of the missing narcotic.
During an observation on 3/27/23 at 3:15 P.M., showed:
-The 100/200 unit medication cart had a lock in the front top of the cart which had to be unlocked before the narcotic drawer could be exposed and unlocked.
-The narcotic drawer did not automatically lock when the lid was dropped down.
-The only way the narcotic drawer locked was if physically pushed down.
-If the narcotic drawer was not physically pushed down to lock, and the medication cart was closed, locking the top main lock, if that top main lock was unlocked, the cart opened and the narcotic drawer would automatically pop up wide open.
-This made it vulnerable for being unlocked even if the main cart was locked, making it easier to get into the narcotic drawer.
During an interview on 3/29/23 at 11:30 A.M., RN A said:
-He/she checked the resident's card of 30 Hydrocodone-Acetaminophen 5-325 mg for the resident in when the pharmacy delivered it.
-He/she signed it in but neglected to immediately place the drug on the master narcotic count sheet.
-The resident's sheet was in the book however.
-He/she now knew he/she needed to immediately add the drug to the master sheet.
During an interview on 3/29/23 at 3:20 P.M., RN C said:
-He/she did not work Friday night but did work Saturday night 3/18/23.
-He/she and LPN A found the count to be off and immediately called the DON.
-All the staff looked everywhere but were unable to locate the card of narcotics for Resident #1.
During an interview on 3/29/23 at 4:00 P.M., LPN A said:
-He/she counted with RN B on the morning of 3/18/23 and the count appeared to be correct, although he/she stated that he/she did not double check the cards each time as he/she was checking the book and RN B was checking the cards.
-He/she felt he/she could have been more careful to watch that was the person counting the narcotic cards said was there, was actually there by watching them count the cards.
-He/she felt that all of the nurses got rather lax when it came to double checking as they did not want to offend their co-workers.
-He/she counted the night shift with RN C and that was when they found the resident's missing card of 30 Hydrocodone-Acetaminophen 5-325 mg.
-He/she notified the DON and looked everywhere they could think of to look.
-He/she could not say for certain that he/she always locked both the main cart and the narcotic drawer every time, as the narcotic drawer did not automatically lock unless it was physically pushed down and latched.
-He/she could not remember if he/she took a break off the unit or not as the day was very busy.
-If he/she did take a break off the unit and handed off the narcotics keys, he/she said the nurses did not routinely count with the nurse who took the keys during the break time.
-He/she was extremely upset that the card went missing on his/her watch as nothing like that had ever happened to him/her before.
During an interview on 4/6/23 at 2:50 P.M., the DON said:
-He/she had discovered just since this incident that many of the medication carts did not lock well and that the 100/200 medication cart was especially easy to leave the narcotics drawer unlocked.
-The medication carts were very old and sometimes even random keys could open the medication carts.
-He/she would have expected the nursing staff report to him/her or the Administrator, that the cart locks were not functioning correctly as soon as they noticed the problem.
-He/she was not aware the nursing staff were not counting narcotics when they handed off the narcotics keys for a meal break.
-He/she was not aware the nurse counting at the narcotics book was not watching the number of narcotics medication cards counted as well.
-He/she felt the medication carts needed to be replaced as soon as possible.
-He/she would have expected the nursing staff to count the narcotics every time the narcotics keys changed hands as well as to watch the number of narcotics cards in the drawer even if counting at the narcotics book.
During an interview on 4/6/23 at 3:15 P.M., the Administrator said:
-He/she would ensure that the medication carts were repaired or replaced as soon as possible.
-He/she would have expected the nursing staff follow the policy for narcotic storage and count.
-He/she would reach out to their corporation to ensure the medication cart issues were addressed.
MO00215758
Apr 2022
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain records of authorization forms for two sampled residents (Residents #10 and #8) out of four sampled residents selected for the res...
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Based on interview and record review, the facility failed to maintain records of authorization forms for two sampled residents (Residents #10 and #8) out of four sampled residents selected for the resident fund review, who allowed the facility to manage their funds. The facility census was 47 residents.
1. Record review of the authorization forms showed the absence of authorization forms (forms signed by residents to allow the facility to manage their funds) for Resident's #10 and #8.
During an interview on 4/26/22 at 10:51 A.M., the Business Office Manager (BOM) said:
- He/she had been in that position for about four weeks.
- He/she was not aware of where the previous BOM stored the completed authorization forms for those residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one sampled resident (Resident #21) out of four sampled resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one sampled resident (Resident #21) out of four sampled residents selected for the resident fund review of a spend down plan to assist the resident in lowering his/her balances to within $200.00 of the eligibility limit of $5,035.00, The facility also failed to submit a Third Party Liability (TPL) form (a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after death, to MO Health Net after the death of Resident #269. The facility census was 47 residents.
1. Record review of Resident #21's [DATE] Statement Register, showed a monthly balance of $5,025.38.
Record review of Resident #21' [DATE] Statement Register, showed a monthly balance of $4,885.68.
During an interview on [DATE] at 12:45 P.M., the Business Office Manager (BOM) said:
- He/she had just started his/her position in [DATE].
- He/she was unaware of the balances in Resident #21's account.
During an interview on [DATE] at 1:43 P.M. Resident #21 (a resident who was identified by the annual Minimum Data Set (MDS--a federally mandated assessment tool required to be completed by facility staff for care planning) dated [DATE], as a resident who was able to make himself/herself understood, able to understand others, and a resident who was alert and oriented as evidenced by a BIMS score of 12) said:
-The Social Service Designee (SSD) spoke with him/her about the resident trust many months ago and told her that he/she could place money into it.
-The SSD did not tell him/her that his/her account balance was getting too high.
-He/she did not realize what amount he/she had in his/her resident trust account.
During an interview on [DATE] at 12:46 P.M., the SSD said:
-He/she would only get involved in notifying the residents because he/she went to shop for the residents.
-He/she did not get involved in sending out written notices to the residents whose balances remain above the resource limit.
-He/she would assist the residents in spending down their limits, once he/she knows that a resident needs to spend down their balances.
2. Record review of the Death in Facility Tracking Record MDS dated [DATE], showed, Resident #269 expired on [DATE].
Record review of the TPL form showed:
-Resident #269 expired on [DATE].
-The TPL for Resident #269 was sent to MO HealthNet on [DATE], (an interval of 84 days between the date of death and the date the TPL was sent).
During a phone interview on [DATE] at 12:31 P.M., the Regional Accountant said:
-There was another person in the position of Business Office Manager, during that time.
-That previous person was new to Business Office at that time and did submit a TPL form to MO HealthNet for Resident #296.
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 interview and record review, the facility failed to provide the facility's bed-hold policy notice when transferring the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the facility's bed-hold policy notice when transferring the resident to the hospital for one sampled resident (Resident #29) out of 12 sampled residents. The facility census was 47 residents.
Record review of the facility's bed-holds and returns policy dated March 2017 showed that prior to transfers, residents or resident representatives would be informed in writing of the bed-hold and return policy.
1. Record review of Resident #29's current face sheet showed the resident was admitted to the facility on [DATE], he/she was his/her own responsible party and some of his/her diagnoses included diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), respiratory failure (when fluid builds up in the lungs or when organs can't get enough oxygen-rich blood to function or when the lungs can't properly exchange carbon dioxide for oxygen) and pneumonia (a lung infection).
Record review of the resident's assessments and tracking records showed:
-The resident had an unplanned discharge to an acute hospital on 2/15/22.
-The resident returned to the facility on 2/17/22.
-The resident had an unplanned discharge to an acute hospital on 3/7/22.
-The resident returned to the facility on 3/11/22.
Record review of the resident's medical records showed there were no bed-hold policy notices for 2/15/22 and 3/7/22.
During an interview on 4/26/22 at 12:18 P.M., Licensed Practical Nurse (LPN) E said the nurses were supposed to fill out the discharge notice and bed hold notices when a resident was sent to the hospital.
During an interview on 4/27/22 at 7:30 A.M., LPN E said he/she could not find any bed hold notices for the resident's 2/17/22 and 3/7/22 transfers to the hospital.
During an interview on 4/28/22 at 11:07 A.M., LPN D said:
-A blank transfer/discharge form and a bed hold form were supposed to be kept in the front of each resident's chart.
-The nurse who sent the resident to the hospital should have filled out the transfer/discharge form and bed hold form.
-The nurses have been told to fill out the forms and send them with the resident when going to the hospital.
-If the discharge to the hospital was too urgent and they couldn't get the bed hold form sent with the resident, they were supposed to send the forms later.
During an interview on 4/28/22 at 4:08 P.M., the Administrator (with the acting Director of Nursing present) said the nurses were responsible for sending the bed hold notices with the resident to the hospital or Social Services if it happened during the day.
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 observation, interview, and record review, the facility failed to provide Diabetic (DM a complex disorder of carbohydra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Diabetic (DM a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) shoes (provide support and protection while minimizing pressure points on the feet) with inserts, in a timely manner resulting in a delay in the resident returning to the community and a decline in his/her over all well-being and attitude for one sampled resident (Resident #33) out of 12 sampled residents. The facility census was 47 residents.
Record review of the facility's Foot Care policy, dated [DATE], showed:
-Residents received appropriate care and treatment in order to maintain mobility and foot health.
-Residents were provided with foot care and treatment in accordance with professional standards of practice.
-Overall foot care included the care and treatment of medical conditions associated with foot complications including diabetes.
-Residents were assisted with transportation appointments to and from specialists.
-Residents with foot disorders or medical conditions associated with foot complications were referred to qualified professionals.
Record review of the facility's Referrals, Social Services policy, dated [DATE], showed:
-Social services personnel coordinated most resident referrals with outside agencies.
-Exceptions may have included emergency or specialized services that are arranged directly by a physician or nursing staff.
-Referrals for medical services must be based on physician evaluations of resident need and a related physician order.
-Social services collaborated with the nursing staff or other pertinent disciplines to arrange for services that were ordered by the physician.
-Social services will document the referral in the resident's medical record.
-Social services and administration maintained a listing of referral agencies that provided assistance or therapy to residents with special problems or needs.
-Social services will help arrange transportation to outside agencies clinic appointments as appropriate.
1. Record review of Resident #33's face sheet showed:
-He/she admitted to the facility on [DATE] from the hospital.
-He/she had diagnoses including bipolar disorder (mood disorders characterized usually by alternating episodes of depression and mania), anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and muscle spasms in the back.
-There was no diagnosis of Diabetes Mellitus.
-There was no mention of the resident having acquired an amputation (severing) of his/her right toes.
-NOTE: There was no documentation of the resident coming from the hospital with an order for diabetic shoes/inserts.
Record review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated [DATE], showed he/she:
-Was admitted from a hospital on [DATE].
-He/she had no cognitive impairment.
-Required extensive assistance from one staff member for transfers, walking in his/her room and corridors.
-Had a not steady balance with moving from a seated to standing position, walking, turning around and facing the other direction, moving on and off the toilet, and surface to surface transfers.
Record review of the resident's care plan, dated [DATE], showed he/she required minimal assistance day to day with a goal of being able to maintain his/her independence during the next 90 days with the following staff interventions:
-The resident wanted to have diabetic shoes.
-The Social Service Director (SSD) was working on this.
-The Ombudsman was working with the resident on getting diabetic shoes.
-Staff were to make referrals to services that may assist him/her in getting an apartment and meet his/her needs in the community.
-Staff were to assist in getting a discharge order from primary care physician (PCP).
-The resident was thinking about returning to the community.
--On [DATE] the resident expressed being depressed (mood disorder that causes a persistent feeling of sadness and loss of interest) because of how long it was taking to get a pair of diabetic shoes/inserts and return back to the community.
--On [DATE] the resident put this goal on hold.
Record review of the resident's nurse's note, dated [DATE], showed:
-The facility physician saw the resident in the facility.
-The resident continued to have difficulties with insurance not approving his/her diabetic shoes.
-Examination and documentation done.
-Follow up with the podiatrist.
-NOTE: There was no documentation of a physician's order being written.
-NOTE: There was no documentation of why a physician's order was not written.
Record review of the resident's nurse's notes, dated [DATE], showed:
-The resident was seen by the facility physician.
-The resident was still having issues getting diabetic shoes.
--There was no documentation as to what the specific issue was that the resident was having.
-NOTE: There was no documentation of a physician's order being written.
-NOTE: There was no documentation of why a physician's order was not written.
Record review of the resident's podiatrist visit at the facility on [DATE] showed:
-The resident was seen for painful long thick toe nails on the left foot.
-Resident had trans-metatarsal amputation (surgery to remove all or part of your forefoot. The forefoot includes the metatarsal bones, which are the five long bones between your toes and ankle) of his/her right foot.
-NOTE: There was no documentation addressing the diabetic shoes/inserts.
Record review of the resident's nurse's notes, dated [DATE], showed:
-The resident saw the podiatrist on [DATE].
-A new order for a compression sock to the right foot/leg was to be on in the A.M. and off at bedtime.
-The resident was informed of the new order by the charge nurse.
-New order for custom made diabetic shoes with insert was put on hold until next podiatrist visit scheduled for [DATE].
-There was no documentation addressing why the diabetic shoes with inserts was being put on hold.
Record review of the resident's nurse's notes, dated [DATE], showed:
-The resident was seen by the facility physician.
-No notes regarding his/her prosthesis or diabetic shoes were noted.
Record review of the resident's quarterly MDS, dated [DATE], showed:
-The resident had no cognitive impairment.
-The resident was independent with bed mobility, transfer, walking in room, walking in corridor, locomotion on and off the unit, toilet use, sit to lying, lying to sitting, rolling left to right, sit to stand and transferring.
Record review of the resident's nurse's notes, dated [DATE], showed:
-The resident was seen by the facility physician on [DATE].
-Diabetic foot exam completed for diabetic shoes by the facility physician.
-PLAN: diabetic foot exam performed, custom diabetic shoes with inserts.
--Documentation showed resident education was done.
--Documentation showed to continue with current treatment.
-NOTE: There was no physician's order for diabetic shoes with inserts written.
Record review of the resident's Physician Order Sheet (POS), dated [DATE], showed:
-The resident had an acquired absence of toes on the right foot.
-The resident had Diabetes Mellitus.
-NOTE: There was no physician's order for diabetic shoes/inserts.
Record review of the Social Services Director's note, dated [DATE], showed:
-The resident was seen by the podiatrist on [DATE].
--There was no other documentation to show what care/services was completed on that visit.
--There was no documentation of any new orders received after that visit.
Record review of the Social Services Director's note, dated [DATE], showed he/she was notified by the Ombudsman that the Ombudsman was going to contact the physician/surgeon who did the amputation for an order for diabetic shoes/inserts.
During an interview on [DATE] 2:00 P.M., the resident said:
-He/she came to the facility in June of 2020 for rehabilitation following part of his/her foot including all his/her toes being amputated.
-The resident felt he/she had to stay at the facility due to not getting a prosthesis or diabetic shoes, as he/she felt he/she was not safe to walk in the community to catch the bus to be able to get to work, because of his/her unsteady gait and being unbalanced.
-The facility physician would not write a prescription for the prosthesis or diabetic shoes.
-The physician wrote an order some time ago but the prosthesis clinic wanted a new one as that order was out of date and his/her foot had changed.
-The Social Worker did not assist with his/her prosthesis or diabetic shoes issues.
-He/she believed he/she wouldn't need to be in the facility if he/she had better mobility.
-He/she believed he/she needed the prosthesis or diabetic shoes to have better mobility.
-He/she was afraid of living on his/her own and falling and ending up back at the facility.
During an interview on [DATE] at 4:51 P.M., the resident said:
-He/she qualified for diabetic shoes.
-He/she had a previous order that expired for diabetic shoes from the facility physician.
--He/she couldn't remember when the order was written that expired.
-The facility physician had not written a new order.
-He/she spoke to the Ombudsman.
-The Ombudsman helped get the prosthetic clinic to pay for everything.
-He/she thought he/she should have been able to be discharged back to his/her home a long time ago, but he/she needed to be able to walk to be discharged .
-He/she still had difficulty walking because he/she did not have the appropriate shoes with inserts following the amputation.
During an interview on [DATE] at 9:50 A.M., Licensed Practical Nurse (LPN) B said:
-The prosthetic clinic only needed a statement of necessity for diabetic shoes.
-The facility physician did not provide the needed documentation.
-He/she did not know where the original diabetic shoe/insert order was.
-He/she said the facility did not follow through on getting the diabetic shoes so the Ombudsman stepped in to assist.
-The resident needed a diabetic shoe order and foot exam.
--He/she worked the night shift and was not aware of the resident not having an order as he/she was not involved in the process.
-All other necessary forms had been obtained.
-The resident was having diabetic medication changes.
-He/she did not know why the resident had not discharged from the facility yet.
During an interview on [DATE] at 10:55 A.M., the SSD said:
-He/she was employed at the facility for a year and getting the diabetic shoes for this resident had been going on longer than a year.
-He/she was aware there was no order for diabetic shoes/inserts.
-He/she stopped working on obtaining the physician's order for diabetic shoes/inserts, because the Ombudsman took over.
-The Ombudsman was coordinating with the prosthesis clinic and the facility physician to obtain the prosthetic and the shoes.
-The Ombudsman, facility physician and prosthetic clinic were the only ones working on the issue.
-He/she was not working on the issue.
-The Ombudsman told him/her that he/she was going to talk to the resident's original doctor who did the amputation surgery.
-He/she was unsure of what the plan was, the Ombudsman took over the process.
-Insurance was limited and did not cover the cost.
-The prosthesis clinic was going to donate their time and materials to get the prosthetic for the resident.
-Medicaid would not always pay for prosthetics when the patient was in the nursing home.
-He/she had been in contact with local resources and agencies to assist the resident in transitioning to the community.
-The resident had not been willing to follow through.
-He/she was unsure where the ball was dropped.
During an interview on [DATE] at 1:14 P.M., the Ombudsman said:
-The resident was at the facility for almost two years.
-The resident had lost part of his/her foot and some toes.
-The resident reported needing a prosthetic insert and a pair of diabetic shoes.
-The resident had goals to transition back to the community, but the only hold up was obtaining the shoes and the insert.
-The resident did not believe he/she belonged at the facility.
--He/she agreed with the resident of not needing to be in the facility.
-The resident had a prescription for a shoe insert, but he/she was unsure what the date of the prescription was.
-He/she contacted the local office of the prosthetic clinic.
-The prosthetic clinic agreed to see the resident and provide a device and shoes free of charge.
-The prosthetic clinic needed a new prescription due to the changing shape of the foot and due to weight the resident gained.
-It had been a year since the original prescription was written.
-He/she was trying to get an order for diabetic shoes/inserts.
-He/she called the facility physician's office, sometime in February, and notified the receptionist of the need for an updated prescription and requested another appointment for the resident to see the physician.
-The prosthetic clinic contacted the physician and requested an updated prescription for the device and shoe.
-He/she contacted the prosthesis clinic recently and they had not heard anything from the facility physician.
-He/she was unsure of who or where the ball was dropped.
-The whole process had gone nowhere for close to a year now.
-The resident's main goal was to have a plan for moving out.
Record review of the resident's physician prescription, dated [DATE], showed:
-The type of prosthesis needed was not determined until the physician wrote the prescription on [DATE].
-The physician ordered diabetic shoes with an insert for a diagnosis of Diabetes and amputation.
During an interview on [DATE] at 7:42 A.M., the resident said:
-Not having the prescription from the doctor had hindered him/her from moving back to the community.
-He/she needed to be able to walk to catch the bus so he/she could go to work.
-He/she had a bad attitude as a result of the whole situation.
-He/she felt angry not being able to get the help he/she needed which prolonged his/her attempt to discharge from the facility to the community.
Observation on [DATE] at 7:42 A.M., showed the resident:
-Got up from his/her recliner in his/her room, to walk across the room and had difficulty using his/her right foot while walking.
-Took small, unsteady steps across the room.
-Had trouble with balance and hobbled while walking due to only putting weight on his/her right heel as a result of not having the front part of his/her foot and toes.
-Had a wheel chair in the room to use if needed.
-No other assistive devices were visible in the resident's room.
During an interview on [DATE] at 11:07 A.M., LPN D said:
-The resident had voiced some sadness about being in the facility as long as he/she was.
-The resident had difficulty getting around the facility without any kind of a prosthetic which the facility physician had to order.
-The resident needed diabetic shoes, which the facility physician had to order.
-The resident had specific conversations with the facility physician regarding getting the shoes.
-The resident said the facility physician could not/would not do anything about getting the diabetic shoes because he/she was not the resident's physician.
-NOTE: The facility physician was the resident's assigned facility physician.
During an interview on [DATE] at 4:09 P.M., the Administrator said:
-It was the responsibility of the charge nurse and social services to obtain the needed documents for the resident's prosthesis and diabetic shoes.
-On occasion the Ombudsman stepped in to provide assistance.
-He/she spoke to the Ombudsman who took it upon himself/herself to contact the prosthetic clinic about donating the prosthesis and the diabetic shoes.
-The Ombudsman also spoke to the physician.
-No one asked the Ombudsman to take this whole project on.
-He/she thought the Ombudsman already had what was needed for the process to continue.
-He/she had not received an update from the Ombudsman.
-He/she and the SSD knew it had been going on a long time.
-The SSD said insurance would not pay for the device.
-The resident was receiving Medicaid and did not want to pay for the device while the resident was in the facility.
-He/she was unaware of how long to expect something like this to be taken care.
-He/she hoped it would take less than three months.
-It was the ultimately the responsibility of the SSD for finding the prosthetics.
-He/she was not aware of the resident not having an order for the diabetic shoes/inserts.
During an interview on [DATE] at 4:09 P.M., the Acting Director of Nursing (DON) said:
-He/she would expect the SSD to notify the nursing department of any needed authorizations or the need for a new order.
-He/she found out about the prosthesis diabetic shoes issues this week.
-He/she did not know the resident did not have an order for diabetic shoes/inserts.
During a phone interview on [DATE] at 9:47 A.M., the prosthesis clinic office administrator said:
-The Ombudsman called two months ago regarding the resident.
-He/she had no contact with the resident, only the Ombudsman.
-He/she had no contact with the facility physician or any other facility staff prior to two months ago.
-He/she received a prescription from the facility physician dated [DATE].
-He/she had not received any communication from the physician prior to [DATE].
During a phone interview on [DATE] at 11:36 A.M., the facility physician said:
-His/her office faxed the prescription for the resident's prosthesis and diabetic shoes multiple times over the last year.
-He/she could not remember specific dates the previous prescriptions were written and sent to the prosthesis clinic office.
-He/she would look through the resident's information and send the previous prescriptions that were written.
-NOTE: No documentation was received from the physician regarding the previous prescriptions.
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 observation, interview, and record review, the facility failed to ensure two sampled residents (Residents #38 and #96) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Residents #38 and #96) were safely transferred from one surface to another by the staff using a mechanical lift out of 12 sampled residents. The facility census was 47 residents.
Record review of the facility's policy, Lifting Machine, Using a Mechanical, dated July 2017 showed:
-Two staff members were needed to safely move a resident with a mechanical lift.
-Mechanical lifts may be used to transfer a resident from bed to a chair.
-Staff must be trained and demonstrate competency using the specific machine utilized in the facility.
-Slowly lift the resident, only lift as high as necessary to complete the transfer.
-Gently support the resident as he or she was moved.
-When the transfer destination was reached slowly lower the resident to the receiving surface.
1. Record review of Resident #38's face sheet showed he/she was re-admitted to the facility on [DATE] with the following diagnoses:
-Anemia (a condition in which the blood does not have enough healthy red blood cells).
-Lymphedema (swelling in the arm or leg caused by lymphatic system blockage).
-Glaucoma (a group of eye conditions that can cause blindness).
-Generalized osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down).
Record review of the resident's Care plan dated 7/9/21 showed the resident used a lift for all transfers.
Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool used by the facility for care planning) dated 12/28/21 showed:
-The resident was totally dependent on staff for all activities of daily living.
-The resident was on Hospice (a condition that would result in life expectancy of less than six months).
-The resident was moderately cognitively impaired.
-The resident used a motorized wheelchair.
-The resident used a mechanical lift to be transferred from one surface to another.
Record review of the resident's Physician's Order Sheet (POS) dated March 2022 showed the resident had an order to get up into his/her electric wheelchair.
Observation on 4/26/22 at 10:17 A.M. with Licensed Practical Nurse (LPN) A and Registered Nurse (RN) B showed:
-The resident was being transferred from his/her bed to his/her electric wheelchair following wound treatment to his/her buttocks.
-The staff lifted the resident off the bed using the mechanical lift.
-The mechanical lift bumped into the resident's electric wheelchair multiple times before the staff had the lift lined up with the wheelchair.
-The electric wheelchair's armrest was not removed from the wheelchair resulting in the resident having to be lifted higher in order to go over the arm of the wheelchair.
-The resident was not lifted high enough and the resident's buttocks did not clear the electric wheelchair's control joystick on the wheelchair's arm.
-The resident's buttocks were scraping the arm of the electric wheelchair and the control joystick were scraping where the resident had a wound as the staff tried to put the resident in the seat of the wheelchair.
-The resident was telling the staff what to do throughout the transfer.
During an interview on 4/26/22 at 10:35 A.M. LPN A said:
-He/she had done many mechanical lift transfers.
-He/she usually did the transfers with a Certified Nursing Assistant (CNA), who told him/her what to do during the transfer.
-He/she had education from the facility on mechanical lifts.
-They should have lifted the resident higher to get him/her over the control joystick on the arm of the wheelchair.
During an interview on 4/26/22 at 10:40 A.M. RN B said:
-The staff had a transfer workshop two weeks ago in which they used a live person to transfer.
-They should have lifted the resident higher to get him/her over the control joystick on the arm of the wheelchair.
During an interview on 4/28/22 at 7:45 A.M. the resident said:
-The two nurses that did the transfer did not do as good of a job as the other staff did.
-He/she was jerked around during the transfer.
-CNA's usually transfer him/her and the transfers were better.
-When the CNA's do the transfer, one staff member was working the lift and the other was watching to make sure he/she was in the proper position and was high enough to clear the arm and control joystick on the arm of the wheelchair.
-The staff should have lifted him/her higher up so he/she would not have scraped the wheelchair arm and the control joystick on the arm of the wheelchair.
-He/she shouldn't have to tell staff how to do a transfer, they should know how to do it.
During an interview on 4/28/22 at 8:00 A.M. CNA A said:
-The facility had a class two weeks ago about how to use a mechanical lift.
-There should be two staff members to use the lift.
-One staff member runs the machine.
-One staff member watches the resident to ensure their safety.
-If the wheelchair was bumped during the transfer it could move and cause an accident.
-If the wheelchair was bumped during the transfer the resident had the potential to not be in proper position or not be high enough to clear the arm of the wheelchair and the control joystick.
-When moving the resident in or out of the the wheelchair the resident should clear the arm of the wheelchair and the control joystick.
During an interview on 4/28/22 at 8:30 A.M. the Director of Rehabilitation said:
-He/she gave the class on transfers a couple of weeks ago.
-In the class the staff transferred each other in the mechanical lift.
-The resident should be in a sitting position.
-The wheelchair if electric should have been shut off so it did not move during a transfer.
-The resident should be lifted high enough to go over the arm of the wheelchair and the control joystick.
-The resident should not touch any part of the wheelchair except the seat when the transfer was done correctly.
During an interview on 4/28/22 at 9:00 A.M. LPN D said:
-The staff should ensure the resident was lifted high enough to clear the arm of the wheelchair and the control joystick.
-They just had a class on how to transfer residents safely.
-One of the two staff was to watch the resident during the transfer so they would not hit anything.
During an interview on 4/28/22 at 3:30 P.M. the Acting Director of Nursing (DON) said:
-He/she would expect the resident to be lifted high enough to go over the control joystick on the arm of the wheelchair.
-He/she would have expected there to be two staff members present during a mechanical lift transfer.
-One staff member would use the mechanical lift and the other staff member would watch the resident to ensure the resident was lifted high enough and would not hit anything and would monitor for resident safety.
2. Record review of Resident #96's care plan dated 5/17/21 showed the resident was unable to transfer independently.
Record review of the resident's annual MDS dated [DATE] showed the following staff assessment of the resident:
-admitted to the facility on [DATE].
-Had moderately impaired cognition.
-Was totally dependent upon the physical assistance of two or more staff members for transfers (between two surfaces such as a chair to bed).
-Used a wheelchair for locomotion.
-He/She had a diagnosis of paraplegia (loss of movement of both legs and generally the lower trunk).
-Was 5'3 and weighed 204 pounds.
During an interview on 4/25/22 at 10:49 A.M., the resident said CNA B transferred him/her into his/her bed with the full body mechanical lift by himself/herself last night.
During an interview on 4/25/22 at 1:13 P.M., CNA A said:
-The resident required a full body mechanical lift for transfers.
-He/She walked by the resident's room last night and heard the resident yelling and CNA B talking to the resident in the resident's room.
-The resident's door was closed.
-CNA B was the only person with the resident.
-He/She and another CNA were going to lie the resident down but CNA B said he/she had it.
-He/She walked away and made a phone call.
-CNA B came out of the resident's room alone and the next time he/she walked by the resident's room, the resident was in bed.
During an interview on 4/25/22 at 3:35 P.M., CNA B said:
-He/She used a full body mechanical lift to transfer the resident into his/her bed last night by himself/herself.
-CNA A asked from the hall, Are you good in here? and he/she responded he/she was done.
During an interview on 4/28/22 at 11:07 A.M., LPN D said:
-He/She was the nurse on duty on the evening/night of 4/24/22.
-The resident required a full body mechanical lift to transfer into bed with the assistance of two staff members.
-He/She was not aware CNA B transferred the resident by himself/herself.
-He/She was not near the resident's room when CNA B transferred the resident into bed without any assistance from any other employees.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure food items which were brought in for residents, were labeled with a residents name and date in the North Side resident ...
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Based on observation, interview and record review, the facility failed to ensure food items which were brought in for residents, were labeled with a residents name and date in the North Side resident use refrigerator. This practice potentially affected at least two residents who had food items stored in that refrigerator. The facility census was 47 residents.
Record review of the facility's visitor Food Policy entitled Foods Brought by Family/Visitors and revised in 7/17, showed:
-Food brought to the facility by visitors and family is permitted .
-Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents.
-Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food.
-Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the Use by date
1. Observation with Licensed Practical Nurse (LPN) A on 4/26/22 at 9:28 A.M., showed a bottle of pink lemonade and one container of a food supplement that was not labeled with the at least a resident's name and there was not a clear delineation between the residents' outside food items and the items that were for general use by all residents.
During an interview on 4/26/22 at 9:29 A.M. LPN B said those items should be labeled with both the resident's name and the date they were brought in. He/she also agreed that the organization within that refrigerator needed to clearly distinguish between items for specific residents and items for general use.
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, interview and record review, the facility failed to maintain the condition of two lids of the outdoor dumpsters to ensure they closed properly to prevent the dumpsters from being...
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Based on observation, interview and record review, the facility failed to maintain the condition of two lids of the outdoor dumpsters to ensure they closed properly to prevent the dumpsters from being open. The facility census was 47 residents.
1. Observation with the Maintenance Director and the Housekeeping Account Manager on 4/25/22 at 3:29 P.M, showed a 9 inch (in.) crack and another lid with a 4 in. crack on two lids of the outdoor dumpster.
During an interview on 4/25/22 at 3:30 P.M., the housekeeping Account Manager said the lids have not been cracked very long.
During an interview on 4/25/22 at 3:31 P.M., the Maintenance Director said he/he was unaware of the broken lids of the dumpster.
During an interview on 4/26/22 at 10:04 A.M., the Interim Dietary Manager said he/she did not notice the cracked lids on the outdoor dumpster containers
Record review of the 2009 Food and Drug Administration (FDA) Food Code
Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnables, showed: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.
Chapter 5-501.113 entitled Covering Receptacles, showed: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered:
(A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or
(2) After they are filled; and
(B) With tight-fitting lids or doors if kept outside the food establishment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was documentation from the Hospice (end of life care) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was documentation from the Hospice (end of life care) company's visits which showed which services they had provided to the resident after 2/10/22; to have a signed Physician's order for Hospice services available in the chart, and to have a designated liaison from the facility to communicate with the Hospice company for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents.
Record review of the facility's Policy, Hospice Program dated July 2017 showed Hospice providers who contract with this facility:
-Must have a written agreement with the facility outlining in detail the responsibilities of the facility and the Hospice agency.
-Were held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility.
-Had the responsibility to provide medical direction, nursing, and clinical management of the terminal illness.
-Our facility has designated (name) and (title) to coordinate care provided to the resident by our facility staff and the Hospice staff.
Record review of the Hospice company/facility contract Hospice-Skilled Nursing Facility Contract, dated 10/01/19 showed:
-The agreement was dated March 25, 2021.
-Hospice would conduct and document in writing a patient specific assessment.
-No less than every 15 days the Hospice company would evaluate the patient's progress toward desired outcomes and response to care, and should update the written comprehensive assessment.
-Hospice should designate a member of the Hospice group who should coordinate the overall Hospice care of the Patient to coordinating care between Hospice and the nursing facility.
-The Nursing facility should designate a staff member who should coordinate care with the Hospice company.
-The Nursing facility and Hospice should each prepare and maintain complete and appropriate clinical records concerning each Hospice patient.
1. Record review of Resident #38's face sheet showed he/she was admitted on [DATE] and was re-admitted on [DATE]; it did not show the resident had Multiple Sclerosis (MS an unpredictable disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body).
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool to be completed by the facility staff for care planning) review dated 12/28/21 showed the resident:
-Was totally dependent on staff for all activities of daily living.
-Had Multiple Sclerosis.
Record review of the resident's Hospice notebook showed:
-He/she admitted to Hospice on 3/26/21 for Multiple Sclerosis.
-He/she had a visit from Psychosocial on 3/30/21.
-He/she had visits from the Hospice Registered Nurse (RN) on the following days 1/3/22, 1/6/22, 1/10/22, 1/13/22, 1/20/22, 1/24/22, 1/27/22, 1/31/22, 2/7/22, and 2/10/22.
--There was no documentation after 2/10/22.
-He/she had visits from the Hospice Certified Nursing Assistant (CNA) on 1/3/22, 1/6/22, 1/10/22, 1/13/22, 1/20/22, 1/24/22, and 2/10/22.
--There was no documentation after 2/10/22.
-He/she had a visit from the Chaplin on 1/13/22.
-He/she had a visit from the Social Worker on 2/10/22.
Record review of the resident's nurse's progress notes dated January 2022 showed:
-On 1/3/22 Hospice was at the facility.
-On 1/6/22 the resident continued on Hospice care.
-On 1/11/22 the resident continued on Hospice care.
-On 1/15/22 the resident continued on Hospice care.
-On 1/24/22 the resident continued on Hospice care.
-On 1/25/22 the resident continued on Hospice care.
-On 1/28/22 the resident continued on Hospice care.
Record review of the resident's nurse's progress notes dated February 2022 showed:
-On 2/2/22 the resident continued on Hospice care.
-There were no other progress notes regarding Hospice services.
Record review of the resident's nurse's progress notes dated March 2022 showed:
-On 3/16/22 Hospice was contacted to get a new mattress for the resident and it was delivered.
-On 3/23/22 Hospice got the low airloss mattress.
--Hospice had been under the impression the mattress had already been delivered and not that the resident was still waiting for the mattress to arrive.
Record review of the resident's nurse's progress notes dated April 2022 showed there was no documentation that the resident had been seen by Hospice.
Record review of the resident's Physician's Order Sheet (POS) dated April 2022 showed:
-The resident was a full code.
-There was no order for Hospice services.
During an interview on 4/24/22 at 2:08 P.M. the resident said:
-Hospice comes to see him/her twice a week.
-Hospice assisted him/her with showers, dressing and getting him/her up into his/her electric wheelchair.
Record review of the resident's most current Care Plan showed:
-The resident was placed on Hospice dated 7/9/21.
-The resident continued on Hospice dated 10/10/21.
During an interview on 4/25/22 at 3:25 P.M. MDS Coordinator/Licensed Practical Nurse (LPN) E said:
-The resident was currently on Hospice and had been since 3/26/21.
-There was no order on the resident's April POS signifying that he/she was on Hospice.
-There should have been an order for Hospice every month on the POS.
-There was a Hospice notebook for each resident who was on Hospice services.
-He/ she was not able to find in the notebook where the Hospice staff was at a minimum writing down every time they had visited.
-There was no documentation after 2/10/22.
-The facility did not have a designated person as a liaison with the Hospice company or someone who would oversee when they were visiting.
-The Hospice staff would have talked to the charge nurse but the facility staff do not document the Hospice visit.
-There was no documentation in the Hospice book that showed what the Hospice staff was to do or how often they were to visit with the resident.
-The sign in sheet showed the following visits:
--Chaplin 2/24/22, 3/11/22, 4/12/22.
--Nurse 1/31/22, 3/10/22, 3/14/22, 3/17/22 no documentation in February or April.
--CNA 1/31/22, 2/7/22, 2/10/22, 2/14/22, 2/21/22, and 2/24/22 no documentation after that date.
-The sign in sheet only documented that Hospice staff came into the building.
-There was no documentation of what was done during the visits.
-The Nurse and the CNA usually come together to give the resident a shower.
-He/she did not realize no one was not checking on the Hospice staff or that they were not charting.
During an interview on 4/26/22 at 12:10 the Hospice Nurse RN A said:
-He/she works with the resident.
-The Hospice company and the facility had a contract to see and treat the resident.
-He/she notified the charge nurse about which cares would be provided to the resident.
-He/she documented his/her visit in the Hospice notes.
-The cares would be in the Care Plan by the Hospice Company.
-He/she put the documentation of the cares in his/her computer.
-The case manager from the Hospice company had the notes from the Hospice visits printed out.
-The case manager brought the printed documentation to the facility and put them into the Hospice notebook.
-The Hospice notebook documentation should have been no more than one or two weeks behind.
-The case manager was out of the country and the documentation did not make it into the facility.
-The case manager who was covering had not brought the notes over to the facility.
-There were two nurses that had seen the resident but there was no documentation in the Hospice notebook since February.
-In the past he/she had talked to the previous Administrator as point person but he/she was no longer working at the facility.
-There was not currently a designated point person to coordinate cares with the facility from the facility.
During an interview on 4/26/22 at 2:00 P.M. MDS/ LPN E said:
-He/she had taken a telephone order from the physician on 3/26/21 for Hospice services for the residents.
-He/she had forgotten to put the telephone order on the POS.
Record review of the resident's Hospice notebook on 4/26/22 at 2:30 P.M. showed:
-The Physician order and certification dated 3/26/21 was not signed by the physician.
-The plan of care did not show which staff or how many visits the staff was to make with the resident.
During an interview on 4/28/22 at 9:10 A.M. the Social Service Director said:
-The previous Administrator had been the liaison with the Hospice staff.
-That Administrator had left the facility two months ago.
-The Hospice staff should sign in and verbally let someone in the Administrative office know they were in the facility.
-He/she did not know who was responsible for ensuring there was documentation of Hospice visits.
During an interview on 4/28/22 at 3:30 P.M. the Acting Director of Nursing (DON) said:
-Documentation of the Hospice visits should have been documented every visit in the Hospice binder.
-Someone from the Hospice office would bring the documentation to the facility and put it in the Hospice binder weekly.
-The DON and the MDS coordinator were currently responsible for ensuring the documentation was in the resident's Hospice binder.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to check the Nurse Aide (NA) Registry prior to their most recent hire date for six out of ten sampled employees to ensure they did not have a ...
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Based on interview and record review, the facility failed to check the Nurse Aide (NA) Registry prior to their most recent hire date for six out of ten sampled employees to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 47 residents.
Record review of the facility's Abuse Prevention Program dated as revised 2017 showed the NA registry would be checked prior to employment for each state where a NA has shown to have worked or has listed certification.
1. Record review of the facility's list of employees hired since the facility's last annual survey and the employees' employment files showed:
-Employee A, a Certified Nursing Assistant (CNA), was hired on 4/21/22 and was checked against the NA registry on 7/5/18.
-Employee D, a CNA, was hired on 3/8/22 and was checked against the NA registry on 8/18/21.
-Employee E, a CNA, was hired on 2/21/22 and was checked against the NA registry on 10/16/20.
-Employee F, a CNA, was hired on 3/24/22 and was checked against the NA registry on 1/8/21.
-Employee H, a CNA, was hired on 3/16/22 and was checked against the NA registry on 8/13/21.
-Employee J, a CNA, was hired on 12/30/21 and was not checked against the NA Registry.
During an interview on 4/28/22 at 1:05 P.M., the Administrator said:
-The Administrative Assistant was responsible for completing the NA registry checks.
-The Administrative Assistant was off work.
-The Administrative Assistant worked there for several years and knew to complete a NA registry check prior to hire on all employees.
-The employees who were checked months or years prior to this hire date were employees who were re-hired and they could not find a more recent NA registry check on them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were offered and/or received at leas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were offered and/or received at least two baths or showers per week and to document when residents had showers or refused showers for four sampled residents (Resident #8, #18, #19, and #32) out of 12 sampled residents. The facility census was 47 residents.
The facility did not have a policy related to providing bathing for residents.
1. Record review of Resident #8's face showed he/she was re-admitted to the facility on [DATE] with the following diagnoses:
-Major depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living)
-Muscle weakness.
-Difficulty walking.
-Cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood).
-Migraine (a headache of varying intensity, often accompanied by nausea and sensitivity to light and sound).
Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/25/22 showed:
-The resident needed help with bathing.
-The resident used a wheelchair for mobility.
Record review of the resident's care plan dated 2/4/22 showed he/she:
-Was legally blind.
-Was at risk for falls.
-Required assistance from the staff with bathing and dressing.
During an interview on 4/24/22 at 1:00 P.M. the resident said:
-He/she was not getting frequent baths.
-Maybe one bath a week.
-If he/she did not have a bath he/she felt like there was dirt stuck to his/her skin.
Record review of the resident's shower sheets dated January 2022 showed he/she:
-Had only one shower the week of 1/2/22 to 1/8/22 on 1/5/22.
-Had only one shower the week of 1/9/22 to 1/15/22 on 1/9/22.
-Had only one shower the week of 1/16/22 to 1/22/22 on 1/22/22.
-Had only one shower the week of 1/23/22 to 1/29/22 on 1/27/22.
Record review of the the resident's shower sheets dated February 2022 showed he/she:
-Had only one shower the week of 2/6/22 to 2/12/22 on 2/9/22.
-Had only one shower the week of 2/13/22 to 2/19/22 on 2/16/22.
-Had only one shower the week of 2/17/22 to 2/26/22 on 2/23/22.
Record review of the resident's shower sheet dated March 2022 showed he/she:
-Had only one shower the week of 2/27/22 to 3/5/22 on 3/2/22.
-Had only one shower the week of 3/6/22 to 3/12/22 on 3/9/22.
-Had only one shower the week of 3/13/22 to 3/19/22 on 3/16/22.
Record review showed the resident had no shower sheets after 3/16/22.
During an interview 4/27/22 12:24 PM Licensed Practical Nurse (LPN) B said:
-They don't have enough staff.
-They try to give everyone at least one shower a week.
-The resident does not refuse showers.
-The Certified Nurses Aide's or bath aid would fill out the bath sheet and give it to the wound care nurse.
-The bath sheet was then put into the bin at the Nurses' station.
2. Record review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-Dementia (a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning).
-Unspecified visual disturbance (can include partial or total blindness, blurred vision).
-Unsteadiness on feet.
Record review of the resident's Care Plan dated 12/2/21 showed he/she was unable to bathe independently due to him/her having an unsteady gait, a diagnosis of Dementia, vision changes. He/she had a goal to be able to wash his/her face and upper body independently during next 90 days with the following staff approaches:
-He/she preferred showers.
-Give verbal cues to help prompt the resident.
-Required one person assistance with bathing.
During an interview on 4/24/22 at 5:31 P.M., the resident said:
-He/she doesn't get a weekly shower.
-He/she was supposed to get a shower on Thursdays.
-He/she only got a shower about every other week.
-Someone did his finger and toenails about a week ago.
Record review of the resident's shower sheets dated March 2022 and April 2022 showed he/she:
-Had only one shower in week of 3/1/22 to 3/5/22 on 3/3/22.
-Had no showers in the week of 3/6/22 to 3/12/22.
-Had no showers in the week of 3/13/22 to 3/19/22.
-Had no showers in the week of 3/20/22 to 3/26/22.
-Had no showers in the week of 3/27/22 to 4/2/22.
-Had no showers in the week of 4/3/22 to 4/9/22.
-Had only one shower in the week of 4/10/22 to 4/16/22 on 4/14/22.
-Had no showers in the week of 4/17/22 to 4/23/22.
3. Record review of Resident #32's admission MDS dated [DATE] showed he/she:
-admitted to the facility on [DATE].
-Had unclear speech slurred or mumbled words.
-Had impaired vision, sees large print, but not regular as in newspapers/books.
-Had moderately impaired cognition.
-Had diagnoses of arthritis (painful inflammation and stiffness of the joints), and Dementia.
-Required two person assistance with transfers between surfaces.
-Required one person assistance for bathing.
Record review of the resident's Care Plan dated 3/25/22 showed he/she:
-Had the potential for skin impairment as evidenced by decreased mobility and incontinence.
-Required staff assistance with mobility.
-Required assistance to complete daily activities of care safely.
-NOTE: Assistance required for bathing was not addressed in the resident's care plan.
Record review of the resident's shower sheets dated March 2022 and April 2022 showed:
-Had only one shower in week of 3/1/22 to 3/5/22 on 3/3/22.
-Had no showers in the week of 3/6/22 to 3/12/22.
-Had no showers in the week of 3/13/22 to 3/19/22.
-Had no showers in the week of 3/20/22 to 3/26/22.
-Had no showers in the week of 3/27/22 to 4/2/22.
-Had only one shower in the week of 4/3/22 to 4/9/22 on 4/7/22.
-Had no showers in the week of 4/10/22 to 4/16/22.
-Had no showers in the week of 4/17/22 to 4/23/22.
During an interview on 4/24/22 6:24 P.M., the resident's spouse said:
-He/she visited the resident daily.
-The resident was supposed to receive a shower the three days before going to the hospital for an operation on 3/14/22.
--No bath sheets were available for the three days prior to to the hospitalization.
-The resident was in the hospital for four days returning on 3/18/22.
-The resident did not receive a shower after returning to facility until 4/7/22.
-The resident has not received any showers since 4/7/22.
4. Record review of Resident #19's first annual MDS dated [DATE] showed the following staff assessment of the resident:
-Cognitively intact.
-Made himself/herself understood and understood others.
-Did not reject any cares over the past seven days.
-Was independent with walking and dressing.
-Required physical help in part of bathing.
-Had a diagnosis of a stroke.
Record review of the resident's care plan dated 3/1/22 showed the resident required assistance with bathing.
Record review of the resident's shower sheets for March 2022 and April 2022 showed:
-On 3/1/22, the resident refused a shower.
-On 3/4/22, the resident refused a shower and said he/she would take one on 3/7/22.
-The resident received a shower on 3/7/22.
-There were no shower sheets for 3/8/22 through 4/6/22.
-The resident received a shower on 4/7/22.
-There were no shower sheets for 4/7/22 through 4/24/22.
During an interview on 4/24/22 at 2:29 P.M., the resident said:
-He/she only gets one bed bath per week where he/she has to stand at the sink and wash off.
-He/she would like two showers per week.
-He/she has waited two weeks to get a shower in the recent past.
-It was going on three weeks since he/she last had a shower.
-The residents were not getting showers because the bath aides kept quitting.
During an interview on 4/28/22 at 7:55 A.M., the Social Services Designee said he/she had not heard any concerns about the resident not getting his/her showers.
During an interview on 4/28/22 at 11:07 A.M., LPN D said:
-The resident had not mentioned to him/her that he/she was not getting showers.
-They were supposed to have a day shift shower aide but it had been difficult to keep a shower aide employed.
-They currently have one shower aide.
-The resident would be able to do most of everything by himself/herself in the shower.
-The resident would just need set up assistance and supervision.
5. During an interview on 4/28/22 at 9:36 A.M., the acting Director of Nursing (DON) said:
-They don't have a policy on bathing.
-The residents should be scheduled for two showers per week and more frequently if the resident desired more.
-If a resident refused a shower, the nursing staff should try to make sure the resident gets at least one bath per week.
-If a resident refused a bath twice in one week, the staff should tell the nurse, Social Services or the DON so they can try to figure out what was causing the resident to refuse.
-The nursing staff should be documenting on the shower sheets when the residents get a shower or when they refuse a shower.
-The nursing staff should be keeping record of the residents' showers to make sure they are getting a shower at least once a week.
-He/she thought the showers had been given, but the shower sheets had been lost.
-There's a bath schedule the nursing staff should be following and keeping track of when they are done or not done.
-The charge nurse should oversee the shower schedule for the day and make sure they are done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the temperature of foods on breakfast trays delivered to the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the temperature of foods on breakfast trays delivered to the 300 and 400 Halls at or close to 120 degrees Fahrenheit (ºF ) for at least four residents who were served later in the process of serving. The facility census was 47 residents.
1. Observation of the breakfast meal delivery on 4/26/22 showed:
-At 8:16 A.M., the cart with the breakfast meal trays for the 300 and 400 Hall, was delivered.
-At 8:27 A.M., the temperatures of the foods on the test tray were the following:
--The French Toast was 108 ºF.
--The Sausage patties were 105.1 ºF.
During an interview on 4/26/22 at 9:14 A.M., the Interim Dietary Manager said:
-In the past, the dietary staff served meals with the regular ceramic plates on top of hot plates (a metal surface that is preheated and used for placing a ceramic plate on before the cover is placed over meal before delivery).
-The last time someone from dietary tested a tray was about three weeks prior to the week of 4/26/22.
During an interview on 4/26/22 at 2:55 P.M., Resident #19 (a resident who was identified by the annual Minimum Data Set (MDS---a federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/25/22, as a resident who was able to make himself/herself understood, able to understand others, a resident who was alert and oriented as evidenced by a BIMS score of 13 and had no swallowing disorders) said:
-The food is often cold, when it arrives to his/her room.
-He/she thought the breakfast foods on the morning of 4/26/22 was cold.
-The food may be hot when they first load it on the carts, but by the time they get the food to his/her room, the food is cold.
-He/she did not like the cold food.
-He/she wanted the hot food to be at least medium warm.
During an interview on 4/27/22 at 8:48 A.M., Resident #45 (a resident who was identified by the quarterly MDS dated [DATE], as a resident who was able to make himself/herself understood, able to understand others, a resident who was alert and oriented as evidenced by a BIMS score of 13, and had no swallowing disorders), said:
-Several of the meals were cold.
-He/she has noticed in the past that the eggs and the sausage were cold.
-He/she did not feel very happy when he/she received cold food in his/her room.
During an interview on 4/27/22 at 1:02 P.M., the Registered Dietitian (RD) said he/she expected the dietary staff would check temperatures about once per week per meal.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure the floor behind the ice machine was maintained free from food debris and grime; to ensure the sprinkler head in the wa...
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Based on observation, interview and record review, the facility failed to ensure the floor behind the ice machine was maintained free from food debris and grime; to ensure the sprinkler head in the walk-in refrigerator was free from a buildup of dust; and to ensure the handwashing sink located at the south side of the kitchen drained properly. This practice potentially affected 47 residents who ate food from the kitchen.
1. Observation on 4/26/22 from 5:58 A.M. through 9:23 A.M. showed:
-Heavy buildup of a black colored grime, food particles, including an old piece of sausage patty, behind the ice machine.
-A heavy buildup of dust on a sprinkler head in the walk-in refrigerator.
-A slow draining handswashing sink located in the south side of the kitchen.
During an interview on 4/26/22 at 7:03 A.M., Dietary [NAME] (DC) A said the sink started draining slow a few days ago.
During an interview on 4/26/22 at 7:05 A.M., DA B said he/she did not notify the Maintenance Director about the slow draining sink.
During an interview on 4/26/22 at 8:37 A.M., the Interim Dietary Manager (DM) said:
-He/she has not notified the Maintenance Director about the sprinkler head with the buildup of dust nor the slow draining sink as yet, and he/she noticed the sink draining slow the prior week, during the evening shift.
-Night shift dietary employees are supposed to clean the debris from behind the ice machine.
-It looked horrible behind the ice machine.
-The last time the area behind the ice machine was cleaned a few weeks ago.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:
- In Chapter 3-305.14, During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination.
-In Chapter 5-205.11 Using a Handwashing Sink.
(A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use.
-In Chapter 5-205.15 System Maintained in Good Repair.
A PLUMBING SYSTEM shall be: A) Repaired according to LAW; and B) Maintained in good repair.
- In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.
- In Chapter 6-501.14, part A, Intake and exhaust air ducts shall be cleaned and the filters changed so they are not a source of contamination by dust, dirt, and other materials.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to include the following in its waterborne Illness plan: A plan on how to identify and mitigate waterborne pathogens in vacant rooms; what method the facility used to check for acceptable ranges for control measures; specific steps that would be taken in response to a Legionella ([NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease) positive water sample; and a listing of the members of the water management team. This practice potentially affected all residents. The facility census was 47 residents with licensed capacity of 120 residents.
Record review of Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form, dated 6/15, showed the following areas to verify:
-Page 1 Of the assessment noted that requirements for any occupant rooms taken out of service during specific parts of the year.
-Page 3 Obtain a written copy of the program policy.
-Page 5 Does the facility monitor incoming water parameters (e.g., residual disinfectant, temperature, pH)?
-Page 14 Is there a standard operating procedure (SOP) for shutting down, isolating, and refilling/flushing for water service areas that have been subjected to repair and/or construction interruptions.
Record review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
1. Record review of the facility's Waterborne Illness plan, dated 9/19/19, entitled Water System for the facility showed:
-The absence of a plan on how the facility would mitigate the conditions that could create waterborne illness in those rooms.
-The absence of a method to check acceptable ranges for control measures of the facility' water.
-The absence of specific steps that facility staff would take in response to a legionella positive water sample.
-The absence of a listing of the water management team.
Observation during the Life Safety Code tour on 4/25/22 from 10:26 A.M. through 2:33 P.M., showed the presence of five rooms which were vacant of residents.
During an interview on 4/27/22 at 12:02 P.M., the Maintenance Director said:
-A plan on how and when to run the water faucets in those vacant rooms was not in the facility's waterborne illness plan.
-He/she checked temperatures on a weekly basis and he/she understood that the checking of water temperatures need to be added to the pamphlet as the method the facility used to check acceptable ranges.
-The specific actions which would be taken in response to a legionella positive water sample were not listed in the waterborne illness plan.
-A water management team, nor its members were listed in the waterborne illness plan at time.
Jun 2019
11 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure fall interventions were implemented by staff res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure fall interventions were implemented by staff resulting in a resident, who was at risk for falls and had a history of falls, being left unattended in his/her wheelchair in his/her room resulting in a fall with a Cervical 2 (C2) neck fracture (the hangman's fracture, located at the second bone down from the skull in the cervical neck vertebrae) which required hospitalization and the use of a cervical collar. Additionally, staff failed to implement further fall interventions after the resident returned from the hospital. The resident continued to be left unattended in his/her room in his/her wheelchair and continued to transfer himself/herself independently, and the facility failed to educate the staff on the safest methods for removing the cervical collar for showers and baths to prevent further injury to the resident's neck for one sampled resident (Resident #27) out of 12 sampled residents. The facility census was 41 residents.
The administrator was notified on 6/27/19 at 5:10 P.M. of an Immediate Jeopardy (IJ) which began on 6/15/19. The IJ was removed, as confirmed by surveyor onsite verification on 6/27/19.
Record review of the facility's Accidents and Incidents - Investigating and Reporting Policy, dated July 2017, showed:
-The Nurse/Charge Nurse and/or Nursing Director or Supervisor shall promptly initiate and document investigation of the accident or incident;
-The Report of Incident/Accident shall include any corrective action taken;
-The Report of Incident/Accident must be submitted to the Director of Nursing (DON) within 24 hours of the incident or accident;
-The DON shall ensure the Administrator receives a copy of the Report of Incident/Accident for each occurrence;
-Incident/Accident reports will be reviewed by the safety Committee for trends or safety hazards and individual resident vulnerabilities will be analyzed.
1. Record review of Resident #27's Face Sheet showed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with the following diagnoses:
-Muscle wasting and atrophy (loss of muscle tissue);
-Muscle weakness;
-Lack of coordination;
-Difficulty in walking;
-Urinary incontinence;
-Dementia (impairment of at least two brain functions such as memory loss and judgement) without behavioral disturbance;
-Repeated falls.
Record review of the resident's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) Care Plan, dated 2/18/19, showed:
-One to two staff were needed to transfer the resident;
-When the resident was unable to assist with transfers, staff may use a mechanical lift as needed with the assistance of two staff members.
Record review of the resident's Impaired Vision Care Plan, dated 2/18/19 showed:
-The resident has glasses and regularly chooses not to wear them;
-The resident should be placed away from glare;
-A night light should be left on during the night;
-Furniture in the resident's environment should not be rearranged without the resident requesting this or knowing about it;
-Large print reading material should be offered as the resident desires;
-Staff are to clean the resident's glasses when the resident is willing to wear them.
Record review of the resident's Potential for Falls Care Plan, dated 2/26/18, showed the following interventions:
-Refer for Therapy evaluations as needed;
-Keep area free of clutter;
-Ensure the resident is wearing non-skid socks or shoes during transfers;
-Assist with toileting and mobility as needed;
-Keep call light within reach;
-Educate the resident to ask for staff assistance;
-Staff to transfer the resident to recliner as desired;
-Monitor the resident as needed while in room;
-On 3/29/18 an intervention was added to educate staff on safe transfers;
-On 4/5/18 staff were educated not to leave the resident sitting alone on the side of the bed;
-On 5/29/18 staff were educated to toilet the resident prior to assisting him/her in his/her recliner;
-On 9/15/18 staff were educated not to leave the resident in their wheelchair in his/her room;
-On 9/26/18 the resident was educated to call for help;
-On 10/8/18 staff were to start toileting the resident at night during staff rounds.
Record review of the resident's quarterly Fall Risk Assessment, dated 11/14/18, showed:
-The resident had one to two falls within the previous 90 day period, the latest fall on 9/26/18;
-The resident could only stabilize with physical assistance, had behaviors (such as restlessness or disorganization) and limited vision, had difficulty ambulating, and had health conditions and took medications that increased his/her fall risks;
-The resident was at high risk for falls.
Record review of the resident's Potential for Falls Care Plan, dated 2/26/18, showed an intervention was added on 11/15/18 to bring the resident back to his/her room after meals and transfer (the plan didn't show to what surface the resident was to be transferred).
Record review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff for care planning purposes), dated 2/11/19, showed the resident:
-Was visually impaired. He/She could see large print, but not regular newspaper or book print;
-Was severely cognitively impaired;
-Had disorganized thinking (rambling or incoherent conversation or illogical flow of ideas);
-Needed one-person extensive assistance with walking, toileting and transfers (movement from one surface to another);
-Was only able to stabilize when rising from a seated to a standing position, moving on and off the toilet, transferring and walking with staff assistance;
-Had lower extremity (hips, legs and feet) impairments in range of motion (ROM) on both sides of his/her body;
-Used a walker and a wheelchair for mobility;
-Was frequently incontinent of urine and occasionally incontinent of bowel;
-Had one fall with a non-major injury and one fall with no injuries since the previous quarterly MDS assessment;
-Was taking a diuretic (medication that promotes the formation of urine by the kidneys, often resulting in urinary urgency (a sudden, compelling urge to urinate);
-Received Restorative Aide (RA - A Certified Nurse Assistant (CNA) with specialized training in increasing a resident's strength and mobility) services for ROM three times.
Record review of the resident's Incident Report, dated 1/27/19, showed:
-The incident time was 4:00 P.M.;
-The resident had been assisted into his/her wheelchair and left in his/her room by the Licensed Practical Nurse (LPN) while waiting for supper;
-The resident fell while self-transferring from his/her wheelchair, sustaining a 4 inch by 4 inch hematoma (localized bleeding outside of blood vessels due to disease or trauma) to the right forehead;
-After the fall the call light was placed within reach and the resident was educated to call for help;
-72 hour neurological checks (assessments to include the resident's vital signs (temperature, pulse, respiration and blood pressure); pupil size and reactivity to light; equality of hand grip strength; facial symmetry; level of consciousness and pain) were started at 4:00 P.M.
Record review of the resident's Nurses' Note, dated 1/27/19 at 4:00 P.M., showed:
-The resident was found lying on his/her back on the floor in his/her room;
-Five minutes prior to the fall the resident was asked if he/she would like to be pushed into the Dining Room. The resident replied he/she would like to sit in his/her room for a while. The resident was left in his/her room and attempted to self-transfer, sustaining a hematoma to the right forehead as a result of the fall;
-The resident's physician and responsible party were notified and the resident was placed on 72 hour monitoring;
-The resident attempted to transfer twice following the fall before the shift ended on 1/27/18 and was educated on calling for help.
Record review of the resident's Potential for Falls Care Plan, dated 2/28/18, showed the nurse was educated on 1/27/19 not to leave the resident alone in his/her room as an intervention to prevent further falls.
Record review of the resident's quarterly Fall Risk Assessment, dated 2/11/19, showed:
-The resident's latest fall was on 1/27/19;
-The resident could only stabilize with physical assistance, had behaviors and limited vision, had difficulty ambulating, and had health conditions and took medications that increased his/her fall risks;
-The resident was a high risk for falls.
Record review of the resident's Potential for Falls Care Plan, updated on 2/18/19 when the resident's comprehensive annual Care Plan was updated, showed the fall interventions put into place on 1/27/19 were reflected on the 2/18/19 Fall Care Plan. No new interventions had been added to the 2/18/19 Fall Care Plan.
Record review of the resident's Nurses' Note, dated 4/27/19 at 5:00 P.M., showed:
-The resident was found in his/her room on the floor facing the doorway with his/her head close to the chest of drawers after the nurse and a Certified Nurse Aide (CNA) heard a noise from the hallway;
-The resident said his/her head felt warm, but did not complain of dizziness or pain;
-The resident had tried to stand up by him/herself from his/her wheelchair;
-The resident required one-person assistance due to unsteady gait and balance;
-Neurological checks were started and the resident's Primary Care Physician (PCP) was notified;
-The resident was assisted up off the floor and into his/her wheelchair and brought to the nurses' station for further assessment.
Record review of the resident's Incident Report, dated 4/27/19, showed:
-The fall happened at 5:00 P.M. in the resident's room;
-The CNA dressed and assisted the resident into his/her wheelchair and left the resident in his/her room;
-The CNA and the Nurse found the resident on the floor;
-The fall was unwitnessed by staff working at the time of the fall;
-The resident was in his/her wheelchair trying to transfer him/herself and had been walking with his/her walker;
-The resident's condition at the time of the fall was listed as:
--Had a fall history;
--Had Arthritis (disorder that affects the joints, causing pain, swelling and stiffness) and/or Osteoporosis (a bone disease causing weakened and porous bones which are more susceptible to breaks);
--Was confused or disoriented;
--Had incontinence and bowel and bladder urgency;
--Had sensory limitations (disabilities related to sight, hearing, touch, taste or smell, which can affect how an individual gathers information from the environment);
-The Root Cause Analysis (a process used to identity reasons for a problem and possible solutions) summary showed:
--The possible causal factor for the fall was listed as the resident likes to lay in bed when not in the Dining Room;
--The reason for the fall was listed as the resident was in his/her wheelchair and tried to transfer him/herself;
--The solutions implemented at the time were:
--Encourage resident to wait for assistance before starting to transfer;
--After toileting, transfer the resident back into his/her recliner or bed.
Record review of the resident's Potential for Falls Care Plan, dated 2/18/19, showed the intervention to encourage the resident to wait for assistance before standing or transferring himself/herself was added to the care plan on 4/27/19. This intervention was similar to two interventions already in place. These included:
--Educate resident to ask for staff assistance;
--The resident was educated to call for help.
Record review of the resident's Fall Risk Assessment, dated 5/9/19, showed:
-The resident's last fall was on 4/27/19;
-The resident could only stabilize himself/herself with assistance, had behaviors and limited vision, had difficulty ambulating and had health conditions and took medications that increased his/her fall risks;
-The resident was a high risk for falls.
Record review of the resident's quarterly MDS, dated [DATE], showed:
-Information about the resident was the same as at the time of the 2/11/19 MDS except as follows:
-The resident was moderately cognitively impaired;
-The resident had one non-injury fall since 2/11/19;
-The resident received RA services twice.
Record review of the resident's Quarterly Care Plan Review, dated 5/13/19, showed the resident:
-Was up daily in his/her wheelchair for locomotion;
-Was assisted by one staff members for transfers and toileting;
-RA was working on ambulation, upper and lower extremity (arms and legs) ROM, and wheelchair positioning and mobility. The resident sometimes refused RA services.
Record review of the resident's Incident Report, dated 6/15/19, showed:
-Between 8:15 P.M. and 8:30 P.M. a CNA and a LPN heard yelling from down the hall;
-The resident was found lying on the floor on his/her left side under his/her walker in front of his/her mini fridge;
-The resident said he/she was trying to transfer from his/her wheelchair to his/her bed;
-After the fall the resident had a hematoma on the left side of his/her head and swelling on the fourth and fifth fingers of the left hand;
-The resident Neurological Assessment Flow Sheet showed the resident's neurological check was completed at 8:30 P.M.;
-The resident was assisted back into his/her wheelchair and monitored at the Nurse's station while the resident's physician was being contacted and orders were obtained to transfer the resident to the hospital;
-The legal representative was notified and the resident was transferred to the hospital at 8:45 P.M.;
-The Root Cause Analysis showed:
--The causal factor was listed as the resident likes being in his/her bed or recliner;
--The reason for the problem was listed as the resident was in his/her wheelchair and transferred himself/herself;
--The solution implemented was listed as the resident was sent to the hospital.
Record review of the resident's Nurses' Notes, dated June 2019, showed staff did not document on 6/15/19 about the incident, injuries or transfer to the hospital.
Record review of the resident's acute medical hospital's discharge information, submitted 6/18/19, showed:
-On 6/16/19 the resident had a Computed Tomography Angiography (CTA (Cat Scan) a high technology X-ray scanner using computer analysis that takes images from different angles and uses intravenous (through the vein) dye injection to provide 3-dimensional images of blood vessels (tubular structures carrying blood through tissues and organs) of the neck. Impressions showed a Type II dens fracture (break at the peg-like process on the second cervical (neck) vertebrae (spinal bone) on which C1 (first cervical vertebrae) rotates. There were no findings of displacement or vertebral artery dissection or occlusion (tear in the artery);
-On 6/18/19 Cervical Spine views were obtained to compare with the CTA completed on 6/16/19. Impressions were Non-displaced Type II Dens Fracture;
-Discharge Physician Orders, Instructions and Primary Diagnosis, dated 6/18/19 showed:
--Primary diagnosis of C2 Fracture.
--C-Collar (cervical brace to support the neck of persons who have had traumatic neck injures) in place at all times. Phili Collar (Philadelphia Collar - a neck brace used to prevent head and neck movement after a spinal injury) when showering;
--Follow up with Neuro surgery in eight weeks. Schedule AP/Lateral X-Ray of cervical spine with C-Collar in place prior to follow-up appointment;
--The hospital's discharge information did not contain specific instructions on how to change out the neck collar and replace it with the shower neck collar, how to hold the resident's neck during the replacement to prevent further injury to the resident.
Record review of the resident's Nurses' Note, dated 6/18/19, showed:
-The resident's return to the facility following a hospital stay;
-The resident was to receive Physical Therapy (PT - treatment of injury through exercise, massage and/or heat), Occupational Therapy (OT - restoration of abilities through performing activities required in daily life) and Speech Therapy (ST - therapy to restore or improve cognition, speech or swallowing abilities) services;
-Nursing was to follow up with scheduling the resident's Neurosurgery appointment.
Record review of the resident's Physician Order Sheet, dated June 2019, showed:
-Orders beginning 6/18/19 for OT, PT and ST, all five times per week for four weeks;
-Orders beginning 6/18/19 for C-Collar on at all times for eight weeks and Phili Collar for showers for Odontoid (tooth-like projection from the second cervical vertebra on which the first vertebra pivots), Type II Dens Fracture). There were no specific instructions for changing out the neck collars.
Record review of the resident's PT Initial Treatment Plan for Rehabilitation, dated 6/18/19, showed:
-Long Term Outcome Goals were for the resident to increase:
--Bed mobility;
--Lower extremity strength;
--Transfers to moderately independent;
--Gait to 150 foot with four-wheel walker and stand-by assistance; and
--Standing balance.
Record review of the resident's OT Initial Plan for Rehabilitation, dated 6/18/19, showed:
-Long Term Outcome Goals were to:
--Complete toileting tasks with good standing tolerance and balance with moderate assistance;
--Completing transfers from multiple surfaces with moderate assistance; and
--Increasing upper extremity strength and tolerance to propel self to 150 feet.
Record review of Nursing Notes, dated 1/28/19 through 6/25/19, showed the facility was not documenting on the resident's attempts to transfer without assistance on the dates when there were no falls.
Observation on 6/24/19 at 10:05 A.M., showed:
-The resident was alone in his/her room sitting in his/her recliner wearing the C-Collar;
-During a five minute interaction with the resident he/she did not attempt to get out of the recliner or state he/she didn't want to be in the recliner.
Observation on 6/24/19 between 12:25 P.M. and 12:55 P.M., showed:
-The resident was eating lunch in the dining room and wearing his/her C-Collar;
-During the observation the resident was focused on the meal and was not attempting to leave the area to go to his/her room.
Observation on 6/24/19 at 1:56 A.M., showed:
-The resident was alone in his/her room sitting in his/her recliner wearing the C-Collar;
-During a fifteen minute interaction with the resident he/she did not attempt to get out of the recliner or state he/she didn't want to be in the recliner.
During an interview on 6/24/19 at 1:56 P.M., the resident said:
-He/She recently cracked his/her neck and hit his/her head and had to go to the hospital;
-He/She slipped and fell in his/her room and the staff heard the fall and came to assist;
-Prior to the fall he/she was walking with his/her walker, which he/she still does with PT and OT.
Observation on 6/25/19 at 1:47 P.M., showed:
-The resident was alone in his/her room and calmly sat in his/her recliner with no attempts to get out of the recliner.
During an interview on 6/27/19 at 7:50 P.M., LPN B said:
-On 4/27/19 the resident was found on the floor facing the doorway with his/her head close to the dresser;
-The resident said that he/she was trying to get up to walk and tried to stand up from his/her wheelchair and fell;
-He/She had CNAs bring the resident up to the Nurses' Station to complete Neuro checks and to prevent the resident from being alone in his/her room;
-Nurses can put small interventions in place such as making sure lighting is good, shoes and/or non-skid socks are worn and the call light is within reach;
-If falls are recurring the charge nurse, DON and MDS Coordinator work collaboratively to put interventions in place;
-The charge nurse assesses the resident following a fall, fills out the Incident Report based on information from the resident and/or CNA and has staff fill out witness or non-witness statements;
-The DON completed Investigations and tried to determine the cause of falls and interventions to address the reason for the falls, often with input from Nursing.
During a telephone interview on 6/28/19 at 10:50 A.M., LPN F said:
-On the evening of 6/15/19 he/she heard yelling from the resident's room and found the resident lying on the floor in his/her room. The resident said he/she was trying to transfer from his/her wheelchair into his/her bed. He/She checked the resident for injuries and contacted the Emergency Medical System (EMS), the resident's physician and family after determining the resident had sustained injuries.
-After a fall nurses check the resident for signs of injury. If the fall was unwitnessed and the resident can't explain what happened or if the resident hit his/her head nurses do Neuro checks and then contact the doctor immediately after assessing the resident. We contact the DON and, as soon as possible, contact the family;
-He/She usually worked weekends beginning at 3:00 P.M. or 4:00 P.M. and observed the supper meals. The meal usually ended around 6:30 P.M.;
-The resident was impatient and wants to be in bed immediately following supper. As soon as the supper meal ends he/she tries to make sure the resident receives his/her evening hygiene care and is safely transferred into bed. Otherwise the resident tries to transfer himself/herself into his/her bed without help which was not safe for him/her.
During an interview on 6/25/19 at 1:53 P.M., Licensed Practical Nurse (LPN) D said:
-The resident has a history of falling every two to three months;
-The resident fell at one point when he/she was working and sustained a hematoma on the forehead;
-He/She was not here when the resident had his/her most recent fall. He/She was told the resident was attempting to transfer from his/her wheelchair to bed and fell backwards;
-The resident required frequent staff reminders and encouragement to allow staff to help with transfers;
-After lunch the resident is ready for bed and staff have to catch him/her immediately following the meal so the resident doesn't try to self-transfer.
During an interview on 6/26/19 at 6:32 A.M., Certified Medication Technician (CMT) A said:
-In late April the resident fell and hit his/her head while attempting to self-transfer;
-The resident needed at least one person to help him/her transfer. He/she shouldn't be transferring himself/herself.
During an interview on 6/26/19 at 6:53 A.M., LPN E said:
-The resident required one-person assistance for transfers;
-After dinner the resident wants to go to bed very early. The staff know that is what the resident wants to do, although the resident might sit for a short while in his/her recliner;
-The resident is the first person assisted to bed after everyone is finished with supper and the resident's bed is lowered to the floor;
-Staff are to put the call light within the resident's reach. The resident rarely puts his/her call light on and, if awake, staff needs to ask him/her if he/she needs anything or needs to toilet and take him/her promptly, checking on the resident at least every two hours.
Observation on 6/26/19 at 7:00 A.M., showed the resident was lying still in bed with eyes closed wearing the C-Collar.
During an interview on 6/26/19 at 9:10 A.M., Certified Nurse Aide (CNA) G said:
-The resident required one-person transfer assistance using a gait belt (safety device worn around the waist, providing support to help prevent falls);
-He/She didn't know why the resident had a collar on and was not told any special instructions related to the C-Collar.
During an interview on 6/26/19 at 11:06 A.M., LPN C said:
-When a resident falls the charge nurse completes the incident report for falls, assesses the resident following falls, and has staff write witness statements;
-He/She puts the report in a box for the Director of Nursing (DON) to review; and
-Charge nurses complete admission assessments after admissions and re-admissions and were responsible for standard fall interventions following re-admissions.
During an interview on 6/26/19 at 11:37 A.M., CNA C said:
-The resident's transfer status was one-person stand by assist with a gait belt before the last fall;
-The Therapy book showed the resident's current transfer status. (At this point CNA C looked in the Therapy book and was unable to find the resident's transfer status);
-The CNA Book should show the resident's transfer status. (CNA C got out the CNA Book and was unable to find the resident's transfer status);
-When the resident returned from the hospital he/she asked the nurse the resident's transfer status and was told the resident transferred with one-person assistance using a gait belt;
-He/She didn't know if any new interventions were added to the resident's Fall Care Plan following his/her most recent fall of 6/15/19, although the resident started therapy after returning to the facility following his/her last fall.
During an interview on 6/26/19 at 4:10 P.M., the DON and the Regional Nurse A said:
-The charge nurse was responsible for obtaining witness and non-witness statements for completing Incident Reports;
-There should have been new interventions in place after the resident returned from the hospital with a neck fracture;
-He/She was responsible for putting new interventions in place;
-No instructions were received on how to care for the resident with the neck brace;
-He/She was responsible for putting the intervention in place upon return from the hospital;
-Staff should be following all fall interventions put in place for the resident.
During an interview on 6/26/19 at 4:50 P.M., LPN A said:
-Therapy provided instruction on transferring the resident using one staff person and a gait belt;
-He/She had not received instruction from PT or any other source on removing the resident's C-Collar for putting on the Phili Collar and didn't know if any nurses had received such training;
-He/She didn't feel comfortable removing the collar without first receiving instruction.
During an interview on 6/26/19 at 5:43 P.M., the DON said:
-The resident's C-Collar should only be removed for showers and the Phili Collar should be worn during showers;
-The DON was responsible for ensuring instruction related to the resident's collars.
During an interview on 6/27/19 at 9:50 A.M., LPN A said:
-He/She spoke with the DON the day before for clarification on the resident's neck collars;
-He/She was instructed for the nurse take the C Collar off. The Phili Collar was to be worn during showers;
-He/She wasn't sure if a nurse had to apply the Phili Collar or if a nurse had to ensure the resident's head did not move or if a CNA could do that, but thought probably two nurses should be involved with changing out the neck collars.
During an interview on 6/26/19 at 1:57 P.M., LPN A said:
-The resident had a long history of self-transfers;
-He/She has had to provide the resident frequent reminders to use the call light for help with transfers and had educated the resident on the dangers of self-transferring;
-The resident always wanted to go to the rest room or be in his/her bed;
-He/She would use the toilet and then go to bed from his/her wheelchair;
-He/She would usually try to self-transfer after meals;
-CNAs were supposed to take the resident to the toilet after meals and then to bed;
-Staff were to transfer the resident to a regular chair in the dining room so he/she didn't wander off without staff knowledge;
-Since the resident's neck fracture he/she has observed the resident sitting on the side of his/her bed. It appeared as if the resident had transferred him/herself to bed;
-When asked, the resident stated he/she transferred himself/herself without staff assistance.
During an interview on 6/27/19 at 2:00 P.M., CNA C said
-The resident was frequently caught trying to transfer himself/herself from his/her wheelchair into bed;
-The resident had been self-transferring for almost five years;
-The resident will go to his/her room after meals to go to bed and was usually was caught trying to self-transfer;
-He/She had been told by the nurses to not remove the C Collar, that nurses had to remove it;
-If the resident showers the nurses have to readjust the collar;
-He/She didn't know what a Phili Collar was and was not educated beyond being told not to touch the resident's collar;
-The resident preferred his/her door to be closed, but for safety reasons the door was kept open and the CNA would walk by the resident's room about every 15 minutes to check on him/her.
During an interview on 6/27/19 at 2:02 P.M., CNA G said:
-The resident transferred himself/herself from his/her wheelchair into bed or to the toilet and back to his/her wheelchair;
-The resident did not transfer himself/herself out of bed as far as the CNA knew;
-He/She had also heard other staff mention how the resident unsafely self-transferred;
-Since the last fall of 6/15/19 he/she had seen the resident attempting to transfer himself/herself and assisted the resident when he/she observed the resident self-transferring. The resident was not supposed to self-transfer;
-After meals the resident doesn't want to wait for someone to help him/her and will put himself/herself to bed;
-Whenever he/she observed the resident self-transferring, the resident was trying to get either to the bathroom or into bed.
During an interview on 6/27/19 at 2:15 P.M. with Physical Therapist (PT) A and Occupational Therapist (OT) A:
-PT A said:
--After the fall of 6/15/19 the resident required more cueing,instruction and encouragement such as instruction on hand placement during transfers;
--The Physical Therapy Assistant normally worked with the resident. He/She didn't know what type of education, if any, the PTA would have provided staff related to the resident's transfer needs;
--The Therapy Department didn't train Nursing staff on how to change out the resident's C-Collar at shower time. The nurses should be qualified to know what to do regarding the neck collars and provide training to the CNAs;
--Therapy staff posted each resident's transfer status on the back of the resident's room doors so that CNAs knew how to transfer each resident;
-OT A said:
--The resident was a one-person assist with gait belt for transfers before the resident's fall on 6/15/19 and the resident continued to need one-person assistance with a gait belt for transfers;
--The resident was working on toileting, transfers, dressing, standing, wheelchair mobility, fine motor control and chair positioning; and
--The resident was moving a little slower after his/her most recent fall and needed staff to allow him/her more time for each transfer.
Observation on 6/27/19 at 2:30 P.M., showed the resident was lying still in bed with eyes closed wearing the C-Collar.
Observation on 6/28/19 at 8:55 A.M., showed the resident was in the Dining Room sitting in a dining room chair and wearing the C-Collar while eating breakfast.
During an interview on 6/27/19 at 2:56 P.M., the DON said:
-Charge nurses were responsible for filling out Incident Reports at the time of the incident, including having staff complete witness statements, contacting the PCP, family and DON;
-He/She contacted the Administrator, did the investigation and initiated an intervention on the second sheet of the incident report;
-He/She lets the charge nurse know what the initial intervention is and the nurses inform the CNAs;
-He/She hadn't investigated the resident's 6/15/19 fall so no intervention had been put in place. Typically, the investigations are completed the same day as the fall;
-He/She meets with the Interdisciplinary Team (IDT - Nursing, Social Services,
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** Based on observation, interview and record review, the facility failed to re-notify the resident's physician for wound care trea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to re-notify the resident's physician for wound care treatment when the resident's physician did not respond to the fax request for three days, which delayed the correct wound care treatment to the resident's buttocks wound; failed to consistently complete skin care assessments and to complete the resident's wound care to the resident's buttocks wounds that were a Stage 2 (partial thickness loss of skin with exposed dermis (thick layer of living tissue below the epidermis (skin surface) and deteriorated to Stage 3 (full thickness skin loss in which subcutaneous (below the skin) fat may be visible. Slough (soft, moist dead tissue) and/or eschar (black or brown dead tissue) may be visible, but does not obscure the depth of tissue loss) pressure ulcers/pressure injuries (PU/PI) and then deteriorated to unstageable pressure ulcers (If slough or eschar obscures the wound bed it is classified as an Unstageable PU/PI); and failed to put in place preventive measures for pressure relieving surfaces to the resident's bed and wheelchair to prevent further deterioration of the resident's pressure ulcers and the prevention of new pressure ulcers from occurring for a one sampled resident who was a high risk for developing pressure ulcers (Resident #38) out of 12 sampled residents. The facility census was 41 residents.
Record review of the National Pressure Ulcer Advisory Panel (NPUAP - an independent not-for-profit professional organization dedicated to the prevention and management of PU/PI) Prevention and Treatment of Pressure Ulcers: Support Surfaces Guideline showed:
-Mattress and Bed Support Surfaces for Individuals with Existing Pressure Ulcers/Injuries:
--Individuals with an existing PU/PI are at higher risk for development of additional PU/PI;
--Whenever possible do not position an individual on an existing pressure ulcer;
--Consider replacing the mattress with a support surface that provides more effective pressure redistribution, shear reduction and microclimate control for the individual who cannot be repositioned off an existing PU/PI, is at high risk for additional PU/PI, fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care and/or bottoms out on the existing support surface;
--Select a support surface that provides enhanced pressure redistribution, shear reduction and microclimate control for individuals with Category/Stage 3 and Category/Stage 4 (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in ulcer) PU/PI.
--Beds with air fluidized features (mattresses and other surfaces comprised of tiny beads, suspended by pressurized, temperature-controlled air with a polyester sheet covering the beads) produced better healing outcomes for Category/Stage 3 and Stage 4 pressure ulcers than standard beds;
--Beds with low-air-loss features (mattresses and surfaces composed of inflatable air cushions used to relieve pressure on body parts) resulted in better healing outcomes for Category/Stage 3 and 4 pressure ulcers than foam mattresses;
-Recommendations for Seating Support Surfaces showed:
--Prolonged sitting resulted in a strong predisposition to pressure ulcer development, particularly in the ischial area (the ischium - the sit bones, marking the lateral (sides) boundary of the pelvic outlet);
--Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced;
--Select a cushion that effectively redistributes pressure away from the pressure ulcer;
--Use alternating pressure seating devices judiciously for individuals with existing pressure ulcers, weighing the benefits of off-loading against the potential for instability and shear based on the construction and operation of the cushion;
-Provide complete and accurate training on use and maintenance of support surfaces;
-Nutritional guidelines in PU/PI Prevention and Treatment guidelines showed:
--Screen nutritional status for each individual at risk of or with a pressure ulcer;
--Provide individuals at risk of pressure ulcers vitamin and mineral supplementation when dietary intake is poor or deficiencies are confirmed or suspected; and
--Monitor for signs and symptoms of dehydration;
-Repositioning and Mobilization guidelines for Individuals with Existing PU/PI showed:
--If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum (triangular shaped bone between the hips)/coccyx (the tail bone, located just below the sacrum) or ischium, to minimize pressure, limit sitting to three times a day in periods of 60 minutes or less;
--Avoid seating an individual with an ischial ulcer in a fully erect posture.
Record review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol Policy, revised April 2018, showed:
-The nurse shall describe and document the following:
--Full assessment of pressure sore including location, length, width and depth, presence of exudates (drainage produced by the body in response to tissue damage) or necrotic (dead or devitalized tissue that cannot be salvaged and must be removed for wound healing) tissue;
--Pain assessment;
--The resident's mobility status;
--Current treatments, including support surfaces;
--All active diagnoses;
-The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (the removal of damaged tissue from a wound) approaches, dressings and application of topical agents and will help identify medical interventions related to wound management.
1. Record review of Resident #38's Face Sheet showed the resident was most recently admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of:
-Chronic Kidney Disease (CKD - longstanding disease of the kidneys where the kidneys eventually become unable to filter waste and excess fluids from the blood leading to renal (kidney) failure);
-Type II Diabetes Mellitus (DM - a chronic condition in which the body either doesn't produce enough insulin or it resists insulin, a hormone produced by the pancreas which regulates the amount of glucose (sugar) in the blood);
-Dementia (a group of thinking and social symptoms that interferes with daily functioning, characterized by impairments in at least two brain functions such as memory and judgment) without Behavioral Disturbance;
-Crohn's Disease (chronic inflammation of the bowels, affecting the lining of the digestive tract);
-Ileostomy Status (a surgical opening in the abdominal wall that allows the ileum (end of the small intestines) to release stool);
-Stage 4 left ankle pressure ulcer;
-Acute Osteomyolitis (bone infection, often associated with DM and vascular impairments) of the left ankle and foot.
Record review of the resident's Braden Scale for Predicting Pressure Sore Risk in Home Care (a tool used by health professionals, especially nurses, to assess the resident's risk of developing a Pressure Ulcer), dated 4/26/19, showed the resident:
-Had no sensory limitations in his/her ability to feel and his/her skin was usually dry;
-Was chair-fast;
-Was slightly limited in his/her mobility and was able to make frequent slight changes in his/her body positioning;
-Had excellent nutrition, eating four or more meat and dairy servings a day;
-Had potential problems with friction (rubbing against another object or surface, causing damage to superficial tissue (skin) or shear (damage below the skin). The resident moved feebly or required minimum assistance and his/her skin is likely to slide against sheets or a chair and/or occasionally the resident slides in his/her chair or bed and
-The resident's total Braden score was 19 out of a possible 23. The resident is considered most at risk when the Braden scale is 15 to 18 or lower;
-Body marks such as bruises, skin tears and scars identified on the form were:
--Foley catheter (a tube inserted into the bladder to drain urine into a urinary drainage bag);
--Ileostomy to mid-abdominal incision with approximately 14 staples;
--Left ankle wound: 6 centimeters (cm) by 2 cm, pink to red wound bed with 1.5 cm by 0.5 cm area of yellow slough; and
--There was no description of any skin damage to the buttocks and no skin damage drawn or indicated on the human body diagram of any skin issues other than those that were described narrative.
Record review of the resident's Physician Order Sheet (POS), dated April 2019, showed physician's orders for:
-Zinc Ointment (treats yeast/fungal infections and minor skin irritations) starting 4/26/19. Apply to sacrum and buttocks twice a day until clear. The order did not indicate a reason for the medication;
-Weekly skin assessment to be completed by the licensed nurses every Tuesdays.
Record review of the resident's Treatment Administration Record (TAR), dated April 2019, showed no documentation of skin assessment completed for the month of April or explanation on the back of the TAR why the assessments were not completed.
Record review of the resident's History and Physical, dated 5/3/19, showed:
-The resident had a physical examination on 4/30/19;
-No documentation of skin breakdown on the buttocks.
Record review of the resident's Potential for Skin Injury related to Diabetes Mellitus and Crohn's Disease Care Plan, dated 5/6/19, showed:
-The resident was admitted with a Stage 4 left ankle wound and a surgical wound to the abdomen. A line was drawn through these two admission diagnoses and the word healed was hand-written with no effective date indicated;
-Also hand-written onto the care plan with no effective date indicated, the resident had a left ankle arterial wound (an open wound caused by poor delivery of oxygen to the affected tissue. The reduced blood flow leads to tissue necrosis (death of cells within the skin) and ulceration (inflammation and often lesions - an abnormal area of tissue outside the body that may or may not be cancerous);
-Staff were directed to use the following interventions:
-A pressure reduction mattress for the resident's bed;
-Physician orders for care and treatment;
-Dietician referral to evaluate nutritional status as needed;
-Linens and clothing to be kept as wrinkle free as possible;
-Skin audits according to schedule and as needed (prn);
-Wound consultant to evaluate and treat as needed.
Record review of the resident's Comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff for care planning purposes), dated 5/10/19, showed the resident:
-Moderately cognitively impaired;
-Required extensive two-person assistance with bed mobility and transfers (movement from one surface such as a chair to another surface such as a bed) and limited assistance with dressing and personal hygiene;
-Was at risk for developing Pressure Ulcers;
-Had one unhealed Stage 4 PU/PI present at the time of admission;
-Had a surgical wound;
-Had a pressure reducing device for his/her chair and bed;
-Received PU/PI care and dressings to his/her feet.
Record review of the resident's TAR, dated May 2019, showed no skin assessment completed on 5/7/19 or 5/14/19 and did not contain an explanation on the back of the TAR why the assessment was not completed.
Record review of the resident's TAR, dated May 2019, showed:
-A new physician's order to cleanse the resident's buttocks with Normal Saline (NS - a mild salt solution) and pat dry. Apply Nystatin Cream (an anti-fungal medication) mixed with Collagen Powder (stimulates healing and dissolves to form a protective gel) twice a day (BID) until healed starting on 5/13/19;
-The TAR showed the area was treated twice daily beginning on 5/13/19 except for the evening of 5/16/19 which was left blank;
-No documentation on the back of the TAR to explain why the resident did not receive treatment the evening of 5/16/19;
-A line was drawn beginning on 5/20/19 with the letters DC for discharged .
Record review of the resident's Nurses' Notes, dated 5/20/19 showed the resident was sent to the emergency room for a possible Urinary Tract Infection (UTI). There was no documentation of a PU/PI or any other skin issue on his/her buttocks at the time of transfer.
Record review of the resident's Discharge Medical Information packet from the acute care hospital, dated 5/24/19, showed:
-The following note on the resident's Final Report, dated 5/23/19:
--Resident is continuing to complain of some buttock pain related to his/her superficial skin breakdown in that region;
-The resident's Referral and Transfer Plan, dated 5/24/19, showed under the section Special Needs;
--Sores on the resident's buttocks;
-Comments on the resident's Patient Education Information form, dated 5/24/19, showed:
--Nursing, please pay careful attention to the skin breakdown to the resident's buttocks;
--Resume wound care to the resident's left ankle.
Record review of the Nurses' Notes, dated 5/24/19, showed the resident was readmitted to the facility on [DATE]. There was no documentation of a PU/PI or any other skin issues on the resident's buttocks.
Record review of the resident's Braden Scale for Predicting Pressure Sore Risk in Home Care, dated 5/24/19, showed the resident:
-Had no sensory limitations in his/her ability to feel and his/her skin was usually dry;
-Was chair-fast;
-Was slightly limited in his/her mobility;
-Had excellent nutrition;
-Had potential problems with friction and shear;
-The resident's total Braden score was 19 out of a possible 23;
-Body marks were not described in the narrative section of the report;
-On the human body diagram:
--A surgical scar was drawn with the words Ileostomy abdominal incision written next to it;
--The words Foley catheter were written and a circle was drawn on the body to indicate the location of placement;
--A circle was drawn on the left foot with the words left ankle wound written next to it;
--There was no description of any skin damage to the resident's buttocks or marks indicated on the human body diagram of skin problems in that area;
-Current needs were listed as:
--Occupational Therapy (OT-treatment to develop, recover or maintain meaningful activities such as dressing, hygiene and toileting);
--Physical Therapy (PT-treatment to improve physical functioning through exercise, activities and other non-pharmacological means);
--Wound care;
--Catheter care.
Record review of the resident's Daily Skilled Nursing Notes, dated 5/25/19 through 5/27/19, showed:
-All sections of the form were left blank except for the resident's vital signs (temperature, pulse, respiration, and blood pressure), oxygen needs and presence of a cough;
-No documentation under the Skin category of any PU/PI, Arterial ulcer or any other skin condition;
-No documentation on the back of the form except to get a daily pain level assessment on 5/25/19 and 5/26/19 on the Day Shift.
Record review of the resident's Nursing Progress Notes, dated 5/25/19 through 5/27/19, showed no documentation of a PU/PI or any other skin issues to the resident's buttocks area.
Record review of the resident's Physician Note, dated 5/27/19, showed:
-The resident was seen by the physician on 5/27/19;
-The resident continues to deal with some Stage 1 (Intact skin with localized area of non-blanchable (when pressed gently the skin does not turn a lighter color) erythema (redness) to Stage 2 skin breakdown on the resident's buttocks.
Record review of the resident's Wound Evaluation, dated 5/28/19 at 1:55 P.M., completed by the wound care company showed:
-The resident's right buttock wound was classified as a Stage 3 PU/PI;
-The wound measured 4.12 cm in length, 2.74 cm in width and 0.10 cm in depth;
--There was a small amount of serous drainage (pale yellow and transparent fluid) and no signs of infection;
--The wound bed was described as 40 percent (%) granulation tissue (new vascular tissue in granular form on an ulcer or healing wound surface) and 60% slough;
--Wound edges were described as distinct, with clearly visible outline and normal healthy skin surrounding the wound;
--The wound had no odor, the status was Not healed and an enzyme debridement (removal of damaged tissue) was completed;
--Comments were Yeast rash pretty well resolved. Now has a lot of slough. Changing orders;
--Orders by the wound care physician were to Clean with Saline, Apply Santyl (debridement ointment) nickel thick layer to the wound bed. Apply Vaseline Gauze (gauze impregnated with petroleum jelly) cut to size. Cover with Bordered Gauze (an absorptive dressing that protects the wound and holds the dressing below it in place to maintain a moist wound environment). Change dressing daily to right buttock and as needed for soiling.
Record review of the resident's facility Wound Assessment Reports, dated 5/28/19; showed:
-Identification on 5/28/19 of a Stage 3 PU/PI;
--The PU/PI identified on 5/28/19 was not present upon admission;
--The location of the PU/PI was the right buttock and was referred to as Wound #2;
--The Medical Director and Durable Power of Attorney (DPOA-a person chosen to legally act on one's behalf in the event the person becomes incapacitated) were notified on 5/28/19;
-Treatment orders were pending.
Record review of the resident's Daily Skilled Nursing Notes, dated 5/28/19 through 5/30/19, showed no documentation of a PU/PI on the checklist under the heading of Skin or on the back of the form in the Comments/Concerns section.
Record review of the resident's TAR, dated May 2019, showed the resident had orders to be treated with Zinc Oxide to bilateral buttocks, starting 5/24/19. The TAR did not give a reason for the order. These orders continued through 5/30/19.
Record review of the resident's May 2019, Physician Orders showed an order, dated 5/30/19, to cleanse the wound to right buttock with NS. Apply nickel-thick size layer to wound bed. Apply Vaseline Gauze and border dressing daily and PRN.
Record review of the resident's TAR, dated May 2019, showed:
-An order began on 5/30/19 to cleanse with NS. Apply Santyl, nickel thick to the wound bed. Cover with Vaseline Gauze cut to fit the wound and with a border gauze to the resident's right buttock;
-The resident was first treated with Santyl on 5/31/19.
Record review of the Daily Skilled Nurses' Notes for 5/31/19, 6/1/19 and 6/2/19, showed no documentation under the heading Skin of a PU/PI or of an Arterial wound. Documentation on the back of the form on 6/1/19 showed a note indicating that treatment orders to the buttocks had changed and that the resident should be encouraged to lay down after meals.
Record review of the resident's Wound Evaluation, dated 6/3/19, from the wound care company showed:
-The resident had an Unstageable PU/PI identified on 6/3/19 of the resident's left buttock. This was given a Wound ID number of two (Wound ID #2). The right buttock PU/PI was reassigned Wound ID #3;
--Wound #2 (left buttock) was measured at 3.81 cm by 2.22 cm by 0.10 cm, had moderate amount of slough, small amount of serous (blood tinge) drainage, and had no odors. The PU/PI had 30% granulation tissue and 70% slough;
--The wound status was Not healed and an enzyme debridement was done;
--Wound care orders were: clean the wound with saline, apply Santyl, nickel thick layer to the wound bed. apply Vaseline Gauze cut to size; cover with a border gauze dressing and change dressing daily;
-Wound #3 (right buttock):
--Measurements were 3.38 cm by 1.31 cm by 0.10 cm and had changed from Stage 3 PU/PI to Unstageable with red granulation tissue, moderate amount of slough, a small amount of Serous drainage, no odors, and the slough was mechanically derided. The wound bed had 20% granulation tissue and 80% slough;
--The wound status was Not healed and the wound was described as having increased slough; and
-Treatment orders remained the same.
The facility Wound Assessment Report, dated 6/3/19, showed:
-Information about the wounds was consistent with the wound care company's assessment;
-The right buttock PU/PI was reassigned Wound #3 and the left buttock PU/PI was referred to as Wound #2;
-Both wounds were Unstageable due to slough;
-The resident's Primary Care Physician (PCP) was notified on 6/3/19 of the new PU/PI.
Record review of the resident's TAR, dated June 2019, showed no documentation of a weekly skin assessment completed, due 6/4/19, and no explanation as to why on the back of the TAR.
Record review of the resident's Potential for Skin Injury Care Plan, dated 5/6/19, showed the staff wrote and did not date that the resident had unstageable pressure ulcers to his/her right and left buttocks. No new interventions had been added to the plan.
Record review of the resident's POS, dated June 2019, showed a physician's order to clean the left buttock with NS. Apply Santyl, nickel thick to the wound bed, cover with Vaseline Gauze dressing and cover with a dry dressing beginning 6/5/19.
Record review of the resident's Daily Skilled Nurses Notes for 6/5/19, 6/6/19 and 6/7/19, showed no documentation of PU/PI or of an Arterial wound under the category Skin. Documentation on the back of the form for 6/5/19 showed treatments were completed to the resident's buttocks. Encourage the resident to self-propel and lay down between meals to promote wound healing.
Record review of the resident's 14-Day MDS, dated [DATE], showed the resident's status was the same as at the time of the 5/10/19 MDS, except as follows:
-The resident had disorganized thinking (incoherent, unclear or illogical);
-Had two Unstageable PU/PIs.
Record review of the resident's TAR for June 2019, showed:
-The resident did not receive his/her right and left buttock daily treatments on 6/7/19;
-No documentation on the back of the TAR to show why the resident did not receive his/her treatment.
Record review of the resident's Wound Evaluation, dated 6/10/19, from the wound care company showed:
-Wound #2 (left buttock) was described as:
--Unstageable, measured 3.48 cm by 4.14 cm by 0.10 cm, had 30% granulation tissue and 70% slough. There was a small amount of serous drainage and had no odors;
--The wound status was Not healed;
--An enzymic debridement was done and orders remained unchanged from the previous week; and
--Comments were Larger area. Needs to offload more;
-Wound #3 (right buttock) was described as:
--Unstageable, measured 5.02 cm by 1.52 cm by 0.10 cm; had 40% granulation tissue and 50% slough with 10% epithelialization (process of scab formation covering the denuded (loss of surface layers) skin surface as part of the healing process) and small amount of serous drainage;
--The wound status was Deteriorated and a mechanical debridement was done;
--Comments were Needs to be out of wheelchair more;
--Treatment orders remained unchanged from the previous week.
Record review of the resident's facility-completed Wound Assessment Report, dated 6/10/19, showed:
-Information was consistent with the wound care company's evaluation;
-Wound edges were distinct with normal healthy skin;
-The resident ate approximately 75% of most meals and the resident's weight was stable.
Record review of the resident's Daily Skilled Nurses' Note, dated 6/10/19, 6/11/19 and 6/12/19, showed no documentation under the Skin section of an Arterial wound or of a PU/PI. Documentation for 6/11/19 on the back of the form showed staff were to encourage the resident to lay down after meals and the resident occasionally refuses.
Record review of the resident's TAR, dated June 2019, showed the resident did not receive his/her right and left Buttock treatment on 6/12/19 and 6/15/19. Review showed no documentation on the back of the TAR explaining why the resident did not receive the treatments.
Record review of the resident's Wound Evaluation, dated 6/18/19, from the wound care company showed:
-Wound #2 (left buttock):
--Was classified as Stage 3 PU/PI, had 70% granulation tissue and 30% slough with a small amount of serous drainage and had no odor. Measurements were 3.57 cm by 3.46 cm by 0.10 cm;
--The wound status was Improved and an enzymic debridement was done;
--Comments were 90% better today; and
--Treatment orders remained the same as the previous week;
-Wound #3 (right buttock) showed:
--The wound was Unstageable, with 100% granulation tissue, had a small amount of serous drainage and no odor. Wound measurements were 0.30 cm by 0.24 cm by 0.10 cm;
--A mechanical debridement was done and comments were 40% better;
--The wound status was Improved and orders remained unchanged from the previous week.
Record review of the facility's Wound Assessment Report, dated 6/18/19, showed:
-Information was consistent with the wound care company;
-Wound edges were distinct with normal healthy skin; and
-The resident ate approximately 75% at each meal and his/her weight was stable.
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/19/19, showed the Skin section was not filled out to document the resident's PU/PI and Arterial Ulcer. Daily Skilled notes for 6/20/19 on the back of the form showed staff were to encourage the resident to stay in bed and the resident was non-compliant at times.
Record review of the resident's Fax Transmittal, sent by the Dietician to the resident's PCP, dated 6/20/19 showed:
-Recommendations for a multivitamin with minerals due to Unstageable wounds to resident's right and left buttocks;
-There was no response to the fax request indicating the physician's approval or denial and explanation if denied.
Record review of the resident's POS, dated June 2019, showed the resident was on a regular diet with mechanical soft texture (ground or flaky meats and cooked vegetables). Review showed no orders for a daily multivitamin with minerals.
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/21/19, showed no documentation under the Skin section of a PU/PI
Record review of the resident's TAR, dated June 2019, showed:
-The resident did not receive treatment for the right and left Buttock on 6/22/19 and 6/23/19;
-No explanation on the back of the TAR as to why the resident did not receive these treatments.
Record review of the resident's Daily Skilled Nurses', dated 6/22/19 and 6/23/19, showed on 6/22/19 and 6/23/19 the staff were unable to do treatments to the residents buttocks due to the resident refused to lay down.
Record review of the resident's Wound Evaluation, dated 6/24/19, completed by the wound care company physician showed:
-Wound #2 (left buttock):
--Was a Stage 3 PU/PI with 80% granulation and 20% slough and had a small amount of serosanguious fluid (clear, yellowish, milky or pale pink fluid composed of blood cells mixed with plasma (the liquid part of blood). Wound measurements were 3.24 cm by 3.64 cm by 0.10 cm;
--The wound status was Improved and an enzymic debridement was done. Comments were Better looking; and
--Treatment orders remained unchanged from the previous week;
-Wound #3 (right buttock) documentation showed:
--The PU/PI was Unstageable with 50% granulation tissue and 50% slough. Wound measurements were 4.92 cm by 2.12 cm by 0.10 cm. A small amount of serous drainage was present with no odors;
--The Wound Status was Deteriorated and a mechanical debridement was done;
--Comments were Continue Santyl. May be able to change to collagen (encourages debridement and stimulates tissue growth) soon; and
--Treatment orders remained unchanged from the previous week.
Record review of the resident's facility-completed Wound Assessment Report, dated 6/24/19, showed:
-Information was consistent with the wound physician's evaluation;
-Wound edges were distinct with normal healthy skin; and
-The resident was continuing to eat 75% of most meals and his/her weight was stable.
Record review of the resident's Daily Skilled Nurses' Notes, dated 5/24/19, showed under the Skin category PU/PI was not indicated and this information was not on the back of the form.
Record review of the resident's Nurses' Progress Notes, on 6/24/19 and 6/25/19, showed no documentation of any new skin issues on the resident's buttocks.
Observation on 6/24/19 at 10:40 A.M., showed the resident, sat upright in his/her wheelchair.
During an interview on 6/24/19 at 11:39 A.M., the resident said:
-He/She had sores on his/her left and right buttock;
-He/She got the sores when he/she was at the facility, but wasn't sure exactly how long he/she had the sores;
-He/she received treatment on the sores.
Observation in the resident's room on 6/24/19 at 11:40 A.M., showed:
-The resident had a mattress which looked like the standard facility mattress;
-It was not a specialized mattress such as a Low Air Loss mattress;
-The resident was sitting up in his/her wheelchair on what looked like a foam seat cushion;
-The seat cushion was smashed down where the resident sat on it and about a one to two inch amount of cushion was visible on the edges.
Record review of the resident's TAR, dated June 2019, showed no documentation of a weekly skin assessment, due on 6/25/19, and no explanation as to why on the back of the TAR.
During an interview on 6/25/19 at 5:47 P.M., the Medical Director said:
-He/She expected a full assessment upon a resident's admission, including a skin assessment;
-If a resident has a PU/PI the resident's wound care team can makes recommendations for specialized needs or the facility nurse should contact the resident's PCP related to PU/PI needs such as a Low Air Loss mattress;
-If the PCP is unavailable, as the Medical Director, he/she could be contacted regarding the resident's orders and needs.
During an interview on 6/26/19 at 8:09 A.M., Licensed Practical Nurse (LPN) A said:
-The resident's Arterial wound was found by the shower aide during a shower;
-The resident started wound care with an outside wound care company the following Monday. The outside wound care company does the wound assessments and decides on treatments. The Day shift facility staff does treatments on all the resident's wounds;
-The resident started to decline after the ankle wound;
-The resident likes to be up all day in his/her wheelchair;
-He/She had educated the resident that staying in his/her chair all day doesn't help with healing the wounds, but it is difficult for staff to get him to lay down during the day.
During an interview on 6/26/19 at 8:46 A.M., Certified Nurse Assistant (CNA) G said:
-The resident recently changed from a two-person transfer with a gait belt to a Sit-to-Stand (equipment designed to help residents who lack the strength or muscle control to rise to a standing position) lift with two staff assisting;
-Staff turn residents who are unable to reposition themselves. The resident repositions himself/herself while in bed because he/she sees that the resident has scooted himself/herself around during the night;
-The resident had a recliner, but he/she likes to stay in his/her wheelchair all day long so he/she can move about the building;
-Sometimes the resident will lay down between lunch and dinner.
During an interview on 6/26/19 at 9:30 A.M., LPN A said:
-He/She just gave the resident a pain pill for ankle pain and he/she would start the resident's daily wound care in 15 to 30 minutes;
-On 6/25/19 his/her transfer status had changed from one to two-person assistance using a gait belt to a Sit to Stand lift with two-person assistance;
-The resident had been more independent and did things for hims
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one cognitively impaired sampled resident's (Resident #4's) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one cognitively impaired sampled resident's (Resident #4's) Durable power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) of an injury of unknown origin out of 12 sampled residents. The facility census was 41 residents.
Record review of the facility's Abuse Investigation and Reporting policy, revised on 7/2017, showed all reports of injuries of unknown source should be reported to the resident's responsible party.
1. Record review of Resident #4's Face Sheet showed the resident was admitted to the facility on [DATE] with the following:
-Diagnoses included: Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety); Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems); Difficulty walking;
-Had a family member as his/her DPOA.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by the facility staff for care planning), dated 7/8/18, showed the resident was moderately cognitively impaired.
Record review of the resident's Care Plan, updated on 4/5/19, showed the resident was alert and oriented to himself/herself only.
Record review of the resident's Nurses' Note, dated 5/22/19, showed:
-The nurse was called to the resident's room;
-The resident had a 5.5 centimeter (cm) by 5.5 cm skin tear and bruise with dried blood. The skin tear and the bruise measured 1.25 cm by 1.25 cm on the resident's left forearm;
-A second bruise was noted just below the first bruise which measured 5 cm by 3.5 cm;
-When asked, the resident did not know how this happened;
-The physician was notified and physician's orders were obtained to treat the area;
-The resident's DPOA was not listed as being notified.
Record review of the resident's Incident Report, dated 5/22/19, showed:
-The resident had a skin tear and a bruise;
-A dried skin tear and bruising was found on the resident;
-The physician and the Director of Nursing (DON) were notified;
-Upon investigation, the resident bumped his/her arm on the wheelchair arm rest. The wheelchair arm rest was inspected for sharp edges and none were found. The resident had frail skin and was on a blood thinner daily;
-The resident's DPOA was not listed as being notified.
During an interview on 6/26/19 at 11:06 A.M., Licensed Practical Nurse (LPN) C said:
-The charge nurse completed the incident report and also did the investigation for an injury of unknown origin;
-The nurses were responsible for notifying the physician and the resident's family member/DPOA of the injury.
During an interview on 6/28/18 at 9:22 A.M., LPN B said:
-When an injury of unknown origin was identified, nurses are responsible for notifying the resident's responsible party;
-The resident was cognitively impaired and the resident's responsible party should have been notified of the resident's skin tear.
During an interview on 6/26/19 at 4:10 P.M., the DON said:
-The resident was cognitively impaired;
-He/She expected the charge nurse to notify the resident's DPOA about the skin tear.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to thoroughly investigate an injury of unknown orig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to thoroughly investigate an injury of unknown origin for two sampled residents, including interviewing all staff who might have knowledge of the injury and considering all environmental factors that could have caused the injury for two residents (Resident #4 and #36), including investigating for possible abuse or neglect, in order to find out what caused the injuries so that appropriate corrective action could be taken for two sampled resident (Resident #36 and #4) out of 12 sampled residents. The facility census was 41 residents.
Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed:
-All reports of injuries of unknown source should be investigated thoroughly by facility management;
-The investigation should include: interview the person reporting the incident, interview any potential witnesses, interview the staff members that had contact with the resident (on all shifts), and review all events leading up to the incident.
1. Record review of Resident #4's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:
-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety);
-Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems);
-Difficulty walking.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by the facility staff for care planning) dated 7/8/18 showed the resident:
-Was moderately cognitively impaired;
-Needed extensive staff assistance with transfers and bed mobility;
-Used a wheelchair for mobility.
Record review of the resident's Care Plan, updated on 4/5/19, showed the resident:
-Was only alert and oriented to himself/herself;
-Needed a mechanical lift and two staff members for all transfers;
-Needed the assistance of one staff member for Activities of Daily Living (ADLs-bathing, grooming, hygiene, eating).
Record review of the resident's Nurses' Note, dated 5/22/19, showed:
-The nurse was called to the resident's room;
-The resident had a 5.5 centimeter (cm) by 5.5 cm skin tear and bruise with dried blood. The skin tear and the bruise measured 1.25 cm by 1.25 cm on the resident's left forearm;
-A second bruise was noted just below the first bruise which measured 5 cm by 3.5 cm;
-When asked, the resident did not know how this happened;
-The physician was notified and physician's orders were obtained to treat the area.
Record review of the resident's Incident Report, dated 5/22/19, showed:
-The resident had a skin tear and a bruise;
-A dried skin tear and bruising was found on the resident;
-The physician and the Director of Nursing (DON) were notified;
-Upon investigation, the resident bumped his/her arm on the wheelchair arm rest. The wheelchair arm rest was inspected for sharp edges and none were found. The resident had frail skin and was on a blood thinner daily;
-The root cause was the resident bumped his/her arm on the wheelchair;
-There were no staff interviews or witness statements to determine how this skin tear might have occurred, no other areas of the room reviewed for potential hazards, and no interventions to prevent potential further injury.
Observation on 6/25/19 at 2:08 P.M., showed:
-The resident's left lateral side of his/her elbow;
-There was a small scab on the lower part of the upper arm where the skin tear had been and mainly healed;
-During the observation the resident could not state what happened to his/her arm and did not respond when asked about his/her arm.
During an interview on 6/25/19 at 2:10 P.M., Registered Nurse (RN) A said:
-The resident had a large skin tear, around 5 cm on his/her left arm;
-He/She was unsure of how the skin tear occurred.
During an interview on 6/26/19 at 11:06 A.M., Licensed Practical Nurse (LPN) C said:
-The charge nurse completed the incident report and also did the investigation for an injury of unknown origin;
-He/She would notify the physician and the resident's family member;
-The incident report should contain staff interviews, the time of the injury, an assessment of the injury, and witness statements;
-The incident report was then given to the DON.
During an interview on 6/26/19 at 4:10 P.M., the DON said:
-The nurse was responsible for obtaining witness reports and non-witness reports from the staff and completing the incident reports;
-He/She was responsible for completing the investigation;
-He/She thought the wheelchair arm rest was what gave the resident the skin tear;
-He/She felt around the wheelchair arm and had not felt any sharp edges;
-He/She did not go further on the investigation or check other environmental areas;
-He/She did not put any interventions in place after the skin tear occurred.
During an interview on 6/28/18 at 9:22 A.M., LPN B said:
-The charge nurse completed the incident report and also did the investigation for an injury of unknown origin;
-The investigations should have staff witness statements for that shift to try to determine what happened;
-He/She would not try to get previous witness statements from the shift before, because he/she would assume the skin tear just happened.
2. Record review of Resident #36's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses of Heart Failure (a condition in which the heart doesn't pump as much blood as it should) and Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid).
Record review of the Comprehensive Care Plan, dated 5/30/19, showed the following:
-The resident's Mobility Care Plan showed he/she required one to two person assistance with bed mobility and two person assistance with transfers;
-The resident's Difficulty Recalling Events Care Plan showed he/she was sometimes confused;
-The resident's Potential for Falls Care Plan showed he/she had muscle weakness and required assistance with toileting and mobility.
Record review of the resident's 14-Day Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff for care planning purposes), dated 6/4/19, showed the resident:
-Was moderately cognitively impaired;
-Required extensive two person assistance with transfers;
-Was not steady and was only able to stabilize with assistance;
-Had functional limitation impairments in range of motion (ROM - full movement potential of a joint) of Upper Extremities (UE - shoulder elbow, wrist and hand) and Lower Extremities (LE - hips, knee, ankle and feet); and
-Had one non-injury fall since the previous assessment of 5/28/18.
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/13/19, showed:
The resident had bilateral lower extremity (BLE) edema (swelling), pitting (indentations of the skin, associated with swelling) of the legs and his/her Lower Left Extremity (LLE) had decreased movement;
-A note written on the back of the form at 2:00 P.M. documented the following:
--The resident complained of left leg pain and received as needed (PRN) pain medication earlier that morning;
--The resident is on maximum assistance status for transfers;
--The resident wears TED (Thrombotic Embolic Deterrent - prevents blood clots) hose (compression stockings that help increase circulation to the lower legs) for swelling in BLE;
-A note written at 3:30 P.M. documented the following:
--A fax was sent to the resident's Primary Care Physician (PCP) per resident and family request;
--The fax requested an order for an X-ray of the Left ankle due to complaints of pain and increased swelling to the site. Staff were awaiting a response from the PCP;
--The resident was assisted by two staff members into bed;
--The resident's TED hose were removed from BLEs due to swelling and BLEs were elevated on pillows;
--The resident said his/her leg possibly twisted during an earlier transfer;
--Staff are unsure of the exact incident occurrence;
--Bruising was observed to the resident's ankle.
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/14/19, showed the resident needed one-person limited assistance with transfers, had an unsteady gait and decreased movement in the Right Lower Extremity (RLE) and LLE.
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/15/19, showed:
-The resident needed two-person extensive assistance for transfers;
-The resident had BLE edema and pitting and an unsteady gait;
The resident had decreased movement in his/her LLE;
-A note written on the back of the form by the 7:00 A.M. to 7:00 P.M. shift showed:
--The resident is complaining of LLE pain which was noted to be tender to the touch;
--The resident worked with Therapy in the morning;
--New orders were obtained for Medrol dose pack, an X-ray of the Left ankle and a one-time order for Colchicine (an anti-inflammatory) 0.6 milligram (mg);
--The nurse spoke with the family;
-Night shift Nurses' Notes showed at 10:30 P.M. the resident's X-ray report was received;
--The on-call physician was contacted and notified of the resident's X-ray results;
--The physician gave orders for the resident to be transferred to the emergency room (ER) for evaluation and treatment;
--Tramadol (treats moderate to severe pain), 50 mg was administered;
--The resident's DPOA was notified;
--Emergency Medical Services transported the resident to the acute care hospital at 11:20 P.M.
Record review of the resident's Incident Report and Investigation, dated 6/15/19, showed:
-An investigation summary, completed by the Director of Nursing (DON), which showed the following:
--The resident's left leg pain was assessed on 6/13/19 after the resident complained of pain to the area;
--The resident walked with Therapy staff prior to complaining of pain;
--After the resident complained of pain, slight edema was observed to BLEs which was normal for the resident;
--The resident said he/she got his/her foot tangled up during a transfer;
--Three staff, all of whom worked the Day shift on 6/13/19, were interviewed. Two said there were no problems with transfers on 6/13/19 and Certified Nurse Assistant (CNA) G said the resident's tennis shoe stuck to the floor during the transfer and he/she was unable to move the foot around;
--There were no other staff members interviewed from any other shift, from the Therapy Department or any other staff members who might have had contact with the resident such as Housekeeping or Activities staff;
--The resident wore TED hose and had a history of gout (a form of arthritis (joint disorder) characterized by pain, redness and tenderness);
-A statement written by CNA G showed:
--He/She transferred the resident from his/her wheelchair into his/her bed using a gait belt (a device worn around the waist used by caregivers to assist in the safe movement of a resident);
--The transfer was without incident and the resident showed no signs of pain and had no complaints during or after the transfer;
--In the past the resident's tennis shoes have stuck to the floor preventing his/her feet from smoothly moving, but CNA G did not notice this problem during the transfer in reference;
--The statement was signed on 6/14/19 and it did not show the date of the referenced transfer;
--Review showed there was no other written statements from staff;
-The Incident Report showed an incident date of 6/15/19 when a left ankle fracture was identified;
--The activity was shown as Transferring in the resident's room;
--The on-call physician was notified on 6/15/19 at 2:00 P.M. and the Durable Power of Attorney (DPOA -gives a trusted person, chosen in advance, the legal right to make decisions and/or take care of financial affairs should a person become incapacitated and unable to act on their own behalf) was notified on 6/15/19 at 8:00 P.M.;
--Physician orders were obtained on 6/15/19 for Medrol dose pack (suppresses inflammation); X-ray of the left ankle, Colchicine 0.6 mg one time dose and transfer to the emergency room (ER);
--The X-ray was done on 6/15/19 and showed a fractured ankle and the resident was sent to the emergency room that night;
-The Resident Follow-up Report showed the resident's condition 24 hours following the injury was the resident was alert and oriented (aware) with periods of confusion and had a soft cast to the left leg;
-The Root Cause Analysis (the factor(s) that caused the incident) showed:
--The resident said he/she twisted his/her ankle during the transfer;
-- The resident's tennis shoes stuck to the floor causing difficulty in pivoting (this was in direct contrast to CNA G's written statement, which showed no such problems);
--The solution implemented to prevent further injuries was the resident was changed to a mechanical lift for transfers;
--Review showed no investigation into possible abuse or neglect of an injury of unknown origin and no special measures were taken to ensure the resident's safety until a thorough investigation could be completed.
Record review of the resident's Physician Orders, dated 6/2019, showed orders to send to ER on [DATE] to evaluate and treat for left ankle fracture.
Record review of the resident's Comprehensive Care Plan, dated 5/30/19, showed:
A Fracture Care Plan was added on 6/15/19 which showed the resident:
-Had a fracture of the Left Ankle Bimalleolar (a major ankle injury that involves breaks in two bones, the lateral malleolus (prominence on the outer side of the ankle) and the medial Malleolus (prominence on the inner side of the ankle) at the lower ends of the fibula and tibia (shin bones);
-The resident was non-weightbearing (NWB);
-Required a two-person transfer;
-Needed to keep his/her foot elevated;
-Needed Assistance in repositioning.
Record review of the resident's Radiology Report, dated 6/16/19, showed the resident was diagnosed with Bimalleolar fracture of the Left ankle.
Record review of the Nurses' Notes, dated 6/16/19, showed:
-The resident returned to the facility from the ER at 9:45 A.M. with a diagnosis of Bimalleolar fracture of the Left ankle;
-The resident complained of Left ankle pain. PRN pain medications were administered twice during the 7:00 A.M. to 7:00 P.M. shift;
-The Left ankle was splinted and wrapped by the ER;
-Two-person mechanical lift transfers were initiated.
During an interview on 6/24/19 at 8:52 A.M., the resident said:
-He/She got his/her left foot caught in the side rail while staff were putting him/her to bed one night approximately a week ago;
-He/She didn't know the name of the staff person who put him/her to bed, but said he/she hadn't seen the person since the injury;
-One staff person was transferring him/her before the accident and since the accident they are using a mechanical lift and two staff members.
During an interview on 6/26/19 at 11:14 P.M. the Director of Nursing (DON) said:
-The resident complained of left foot pain on 6/13/19 and told him/her it was from a transfer. The resident couldn't tell him/her if it was from his/her wheelchair into his/her bed or from the bed into the wheelchair;
-The resident named CNA C and CNA G as the staff who transferred him/her the day of the accident, but the name kept changing;
-The foot didn't look out of ordinary. It was swollen, but the resident has swelling;
-The resident went to Therapy earlier that day.
During an interview on 6/26/19 at 4:10 P.M., the DON and Corporate Nurse said:
-Prior to the incident the resident was transferring with one-person assistance;
-He/She did not interview the Night shift about the resident, because the resident's complaint of pain started the morning of 6/13/19 after breakfast and after the resident's therapy. Additionally he/she did not interview Therapy staff as part of the Accident Investigation, because the resident was walking with them that morning;
-The resident had not stated to him/her that he/she got his/her foot caught in the bed.
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 record review and interview, the facility failed to notify the resident's representative in writing of a transfer/disch...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident's representative in writing of a transfer/discharge to the hospital, including the reasons for the transfer for one sampled resident (Resident #6) out of 12 sampled residents. The facility census was 41 residents.
Record review of the facility's Transfer or Discharge Notice, revised on December 2016, showed:
-Under the following circumstances, the notice will be given as soon as it is practicable:
--An immediate transfer or discharge is required by the resident's urgent medical needs;
-The resident and/or representative (sponsor) will be notified in writing of the following information:
--The reason for the transfer or discharge;
--The effective date of the transfer or discharge;
--The location to which the resident is being transferred or discharged .
1. Record review of Resident #6's admission Face Sheet showed:
-The resident was admitted on [DATE] and readmitted on [DATE];
-The resident was his/her own responsible party;
-The resident had two family members listed as contacts;
-The resident had the following diagnoses:
--Atrial fibrillation (A-Fib-abnormal heart rhythm);
--Heart failure (a chronic condition in which the heart doesn't pump blood as well as it should);
--Bradycardia (slower-than-expected heart rate, generally beating fewer than 60 beats per minute).
Record review of the resident's Nurses' Notes, dated 2/28/19 at 12:45 P.M., showed the resident complained of right arm pain radiating across chest and was discharged to the hospital by ambulance at 11:35 A.M.
Record review of the resident's Nurses Notes, dated 3/6/19 at 4:50 P.M., showed the resident returned to the facility.
Record review of the resident's medical record showed no written notification to the resident or Resident's Representative(s) of the resident's transfer to the hospital.
During an interview on 6/27/19 at 11:53 A.M., the Social Services Director (SSD) said he/she is responsible for sending the transfer notification letters to the resident and the resident's representative(s). The SSD said he/she did not send a notification of transfer letter to the resident's family or his/her representative. The SSD said he/she did not send the transfer notification letter to the resident's representative(s), because it was given to the resident.
During an interview on 6/28/19 1:38 P.M., the Director of Nursing (DON) said:
-The SSD should give the notifications of transfer or discharges to the resident if he/she is their own responsible party;
-He/She did not know if the letter of transfer notification also had to be sent to the resident's representative when the resident is their own responsible party;
-The SSD did not send the transfer form to the resident's representative.
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** Based on observation, interview and record review, the facility failed to assess activity preferences and failed to provide mean...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess activity preferences and failed to provide meaningful activities for one cognitively impaired sampled resident (Resident #10) out of 12 sampled residents. The facility census was 41 residents.
Record review of the facility's policy Activity Evaluation, revised June 2018, showed:
-An activity evaluation was conducted as part of the comprehensive assessment to help develop an activities program that reflects the choices and interests of the resident;
-The resident's life-long interests, spirituality, life roles, goals, strengths, needs, and activity pursuit patterns and preferences were included in the evaluation;
-The activity evaluation was used to develop an individual activities care plan that would allow the resident to participate in his/her activities of choice.
1. Record review of Resident #10's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:
-Adult failure to thrive;
-Glaucoma (a condition of increased pressure inside the eye which could lead to blindness).
Record review of the resident's Activity Progress Note, dated 1/16/19, showed the resident:
-Was alert and oriented to himself/herself only;
-Was dependent on the staff for all cares;
-Had played kickball;
-Answered to his/her name and would call out for his/her Mom and Dad;
-The staff did not document how often the resident participated in activities or what his/her activity preferences were.
Record review of the facility's activity schedule, dated 04/2019, showed there were activities scheduled daily including: church, Bible study, art, tea parties, music holiday parties, cards, games, and puzzles, and movies, gardening, cooking, and exercise.
Record review of the resident's activity participation record, dated 4/2019, showed the resident did not participate in any scheduled activities.
Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by the facility staff for care planning), dated 4/8/19, showed:
-The resident was severely cognitively impaired;
-The resident was dependent on staff for all cares and wheelchair mobility;
-The activity preferences could not be completed by the resident or the resident's family member.
Record review of the resident's activity care plan, dated 4/15/19, showed the resident:
-Was more passive in activities;
-Wanted to maintain relationships with family and friends;
-Would spend time out of his/her room each day;
-Needed the assistance of the staff to take him/her to activities of choice;
-He/She liked listening to music and the staff should assist him/her to music activities;
-He/She liked animals;
-He/She liked television on in his/her room at times.
Record review of the resident's annual Activity Assessment, dated 4/18/19, showed:
-The resident was more passive with participation with activities;
-While sitting next to the resident in a church activity, the resident would reach out to touch your hand or hold your hand for a little while;
-The resident did not respond much;
-The resident liked religious services and television;
-The frequency of activities, time of activities, activity patterns and preferences were not completed.
Record review of the facility's activity schedule, dated 5/2019, showed there were activities scheduled daily including: church, Bible study, art, tea parties, music holiday parties, cards, games, and puzzles, and movies, gardening, cooking, and exercise.
Record review of the resident's activity participation record, dated 5/2019, showed the resident participated in two activities during the month.
Record review of the facility's activity schedules, dated 6/2019, showed there were activities scheduled daily including: church, Bible study, art, tea parties, music holiday parties, cards, games, and puzzles, and movies, gardening, cooking, and exercise.
Record review of the resident's activity participation record, dated 6/2019, showed the resident participated in two activities during the month.
Observation on 6/24/19 at 10:04 A.M., showed the Activity Director was taking residents to the activity room for an activity.
Observation on 6/24/19 at 10:16 A.M., showed the Activity Director had five residents in the activity room and was singing a song to the residents.
Observation on 6/24/19 at 10:17 A.M., the resident was in his/her room seated in his/her wheelchair sleeping.
Observation on 6/24/19 at 10:36 A.M., showed the Activity Director was reading out loud to the residents.
Observation on 6/24/19 at 10:59 A.M., showed:
-The resident was in his/her room seated in his/her wheelchair with his/her head down;
-A nail painting activity was being held in the activity room.
Observation on 6/28/19 at 11:08 A.M., showed:
-The resident was in his/her room seated in his/her wheelchair;
-A craft activity had been held in the activity room.
During an interview on 6/28/18 at 9:22 A.M., Licensed Practical Nurse (LPN) B said:
-If a resident did not go to group activities, a one-on-one activity would be good for them or a small group activity;
-The resident liked to watch old western movies and liked to be around other residents;
-The resident would start talking if a movie was on from his/her generation;
-The resident liked interactions from others;
-If you engage the resident, he/she would tell stories of church, his/her children, and his/her sister from the past;
-If he/she was around others he/she would start talking and engage by talking and telling stories.
During an interview on 6/28/19 at 9:52 A.M., the Activity Director said:
-He/She would do a room visit and would hold the resident's hand;
-The resident would get tired at times;
-He/She would take the resident to church activities;
-If the resident was lying down he/she did not bother the residents to invite them to activities;
-He/She was responsible for obtaining the resident's activity preferences from his/her family and updating the information on the MDS and the activity assessment;
-He/She was responsible for assisting residents to activities;
-He/She was responsible for documenting the residents activity participation;
-He/She did not try to call the resident's family to obtain the activity preference; and
-He/She tried to go see the resident once a week.
During an interview on 6/28/19 at 9:58 A.M., Certified Nursing Assistant (CNA) B said:
- When you interact with the resident, he/she would talk;
-The resident did not always make sense with what he/she said, but would be engaged;
-The resident would always interact with him/her;
-The resident always liked to hold hands and liked human touch;
-He/She liked to be around others;
-He/She was people person.
During an interview on 6/28/19 at 10:41 A.M., the MDS Coordinator said:
-The Activity Director was responsible for completing the activity portion of the MDS;
-He/She updated the activity care plans for the residents;
-The resident's family could be contacted for the resident's activity preferences by the Activity Director or the information could be obtained during the care plan meeting;
-The resident's family was here weekly.
During an interview on 6/28/19 at 10:54 A.M., the Social Services Designee (SSD) said:
-He/She expected daily meaningful activities for the residents;
-He/She would talk with the resident and he/she always responded;
-He/She would tell stories of his/her sister and past times;
-He/She would not always track the conversation, but always interacted when talked to;
-He/She should have an individualized activity plan with his/her likes and dislikes.
During an interview on 6/28/19 at 1:38 P.M., the Director of Nursing (DON) said:
-He/She expected the staff to provide meaningful activities for cognitively impaired residents;
-The resident liked to listen to music and do one on ones activities;
-The activities depended on the resident's abilities and what they could do;
-He/She expected the Activity Director to call the family about the resident's activity preferences;
-The Activity Director was responsible for completing the annual MDS portion for activities and completing a thorough annual activity assessment;
-The resident would talk when talked to and did not make sense due to his/her cognitive impairment;
-The resident did not like it very loud;
-The resident needed more one-on-one activities versus big activities that were loud.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #5's admission Face Sheet showed the resident was admitted on [DATE] with the following diagnoses:
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #5's admission Face Sheet showed the resident was admitted on [DATE] with the following diagnoses:
-Restless Leg Syndrome (condition characterized by a nearly irresistible urge to move the legs, typically in the evenings while sitting or lying down and generally worsens with age and can disrupt sleep);
-Difficulty walking;
-Obesity (a disorder involving excessive body fat that increases the risk of health problems).
Record review of the Resident's Annual MDS, dated [DATE], and quarterly MDS, dated [DATE], showed:
-The resident's cognition was intact;
-The resident is a one person physical assist for transfers;
-The resident is a one person physical assist for ambulating;
-Uses a walker in room and a wheelchair for distances;
-Is able to transfer from surface to surface by self;
-The resident is a one person physical assist for dressing;
-The resident is a one person physical assist for toileting and personal hygiene.
Record review of the Resident's Care Plan (written out plan for the care of the resident), dated 4/4/19, showed the resident had:
-Bilateral edema (swelling in the legs caused by the retention of fluid in leg tissues);
-A goal of:
--Edema will not interfere with ability to function;
-Approaches:
--Encourage to elevate legs between activities/meals;
--Monitor circulation, motion and sensation;
--Follow orders from Primary Care Physician (PCP) as given;
--Keep PCP aware of changes or concerns regarding the resident's condition.
Record review of the resident's Physician Order Summary (POS), dated June 2019, showed:
-Wrap BLEs from toes to knees with ace wraps (an elasticated bandage used to restrict blood flow to reduce swelling) before rising and remove at hour of sleep with a start date of 9/18/18.
Record review of the resident's Treatment Administration Record (TAR), dated March 2019, showed:
-The Resident refused to have legs wrapped on 3/22/19, 3/23/19, 3/24/19, and 3/25/19.
Record review of the resident's medical record showed no Physician notification of the resident refusing to to have his/her legs wrapped.
Record review of the resident's Weekly Skin Assessment, dated March 2019, showed:
-Weekly skin assessments were completed;
-The Licensed Practical Nurse (LPN) noted on 3/10/19:
--Both of the resident's legs were pink in color;
--The resident had one plus pitting edema (about a 2 mm slight indentation of swollen skin when pressed and immediately rebounds) in both legs;
--The nurse had encouraged the resident to elevate their legs;
-The LPN noted on 3/21/19:
--Both of the resident's legs had two plus pitting edema (about a 6 mm indentation of swollen skin when pressed which takes a few seconds to rebound rebound);
--The nurse had encouraged resident to elevate their legs.
Record review of the resident's TAR, dated April 2019, showed:
-The resident's legs were not wrapped on 4/22, 4/28, and 4/29/19;
-The staff did not document a reason why the resident's legs were not wrapped.
Record review of the resident's medical record showed no Physician notification of the resident refusing to to have his/her legs wrapped.
Record review of the Resident's Weekly Skin assessment dated [DATE] showed:
-Weekly skin assessments were completed;
-The LPN noted on 4/7/19:
--Both of the resident's legs were pink in color;
--The resident's treatment was in place;
--The resident's legs were wrapped every A.M.;
--The resident's skin was dry, warm, and pink;
-The LPN noted on 4/14/19:
--The resident's treatment was in place;
--There were no other changes from the previous assessment;
-The LPN noted on 4/21/19:
--The resident's treatment was in place;
--There were no other changes from the previous assessment;
-The LPN noted on 4/28/19;
--The resident had dependent edema noted in both of his/her legs;
--The resident's legs were wrapped with ace bandages every A.M.;
--The resident's skin was dry, warm, and color was appropriate.
Record review of the resident's TAR, dated May 2019, showed:
-The resident's legs were not wrapped on 5/17/19, 5/20/19, and 5/31/19;
-The staff did not document a reason why the resident's legs were not wrapped.
Record review of the resident's medical record showed no Physician notification of the resident refusing to to have his/her legs wrapped.
Record review of the Resident's Weekly Skin Assessment, dated May 2019, showed:
-Weekly skin assessments were completed;
-LPN noted on 5/6/19;
--Both of the resident's legs were pink in color;
-LPN noted on 5/12/19;
--There were no changes from the previous assessment;
-LPN noted on 5/23/19; and
--Edema was noted on both of the resident's legs.
Record review of the resident's TAR, dated 6/1/19 through 6/27/19, showed:
-The Resident's legs were wrapped every day except on 6/4/19;
-The staff did not document a reason why the resident's legs were not wrapped.
Record review of the resident's medical record showed no Physician notification of the resident refusing to to have his/her legs wrapped.
Record review of the Resident's Weekly Skin Assessment, dated June 2019, showed:
-Weekly skin assessments were completed;
-LPN noted on 6/2/19:
--The resident's skin was warm and dry;
-LPN noted on 6/9/19:
--The weekly skin assessment was completed;
-LPN noted on 6/17/19:
--The resident had no new skin issues;
-LPN noted on 6/23/19;
--The weekly skin assessment was completed, with no new skin issues.
During an observation and interview on 6/24/19 at 9:54 A.M., of the resident showed:
-The resident was sitting in his/her recliner chair with his/her legs down;
-The resident's legs were not wrapped;
-The resident had swelling in his/her lower legs;
-The Ace wrap bandages were on a table beside a chair;
-The resident said his/her legs were supposed to be wrapped in the mornings and wraps removed at night;
-The resident said the only time his/her legs get wrapped was when Registered Nurse (RN) A is working;
-The resident said turns on his/her call light and tells the nurse that he/she needs his/her legs wrapped;
-The nurses tell him/her they will be right back to wrap his/her legs and never come back;
-He/she has told the DON he/she was not getting his/her legs wrapped every day.
During an observation on 6/24/19 at 1:37 P.M., of the resident showed:
-The resident was sitting in his/her recliner chair with his/her legs elevated;
-The resident's legs were not wrapped;
-The resident had swelling in his/her lower legs.
During an interview on 6/24/19 at 1:37 P.M., the resident said:
-His/Her legs were not wrapped today.
-His/Her legs were supposed to be wrapped in the mornings and wraps removed at night;
-He/she does not take the wraps off.
-The wraps keep the swelling down in his/her legs.
During an observation/interview on 6/26/19 at 8:12 A.M., of the resident showed:
-The resident was sitting in his/her recliner chair with his/her legs elevated;
-The resident's legs were not wrapped;
-The resident had swelling in his/her lower legs;
-He/She said the nurse was waiting for him/her to get his/her shower before wrapping his/her legs.
During an observation on 6/26/19 at 12:15 P.M., of the resident showed:
-The resident was sitting in his/her recliner chair with his/her legs elevated;
-The resident's legs were not wrapped;
-The resident had swelling in his/her lower legs.
During an interview on 6/28/19 at 10:52 A.M., LPN C said:
-Ace wraps should be put on a resident in the morning before they get up or as directed by the physician order for the resident;
-If the Physician's order is to wrap legs daily in the morning, the resident's legs should be wrapped;
-The nurse who wraps a resident's legs should chart on the TAR after doing it;
-He/She was not aware of this resident not having his/her legs wrapped and it being charted that it is being done.
During an interview on 6/28/19 at 11:00 A.M., LPN B said:
-Ace wraps should be put on the resident before he/she gets up out of bed in the mornings;
-There was only one resident at this time with an order for ace wraps;
-This resident:
--Will sleep in the recliner chair;
--Gets up and down during the night and his/her legs swell;
--Gets his/her legs wrapped if he/she is in the recliner chair and allows it;
--Will remove the ace wraps himself/herself after lunch when the wraps are put on in the mornings.
During an interview on 6/28/19 at 1:38 P.M., the DON said:
-He/She expected a resident's daily care orders be done each day;
-He/She expected a nurse to only chart on the TAR when the care was actually done.;
-There was no specific A.M., time frame to put ace wraps on a resident;
-It would depend on when the resident gets up;
-Some residents get up earlier than others;
-This resident liked to get up around 5:00 A.M.
-There is no policy for time frame of wrapping a resident's legs.
Based on observation, interview and record review, the facility failed to fully assess one resident's left ankle pain and swelling after the resident complained his/her left ankle and foot was injured during a transfer on 6/13/19. Facility staff failed to re-notify the resident's physician when the physician had not acknowledged receiving the fax with the resident's change in condition to the left foot and ankle from 6/13/19-6/15/19 which delayed the resident in receiving appropriate care and treatment of a fractured ankle for one sampled resident (Resident #36). Facility staff also failed to follow physician's orders to wrap the resident's lower legs daily and failed to notify the resident's physician when the resident refused to have his/her legs wrapped or if staff did not wrap the resident's legs as ordered for one sampled resident (Resident #5) out of 12 sampled residents. The facility census was 41 residents.
Record review of the facility's Change in Resident Condition or Status policy, revised May 2017, showed:
-The nurse will notify the resident's Attending Physician or physician on-call when there has been an accident or incident involving the resident or discovery of injuries of an unknown source;
-Significant change in the resident's physical, emotional or mental condition;
-Need to transfer the resident to an acute care hospital;
-A nurse will notify the resident's representative when:
--The resident is involved in an accident or incident that results in an injury, including injuries of unknown source;
--There is a significant change in the resident's physical, mental or psychosocial status.
1. Record review of Resident #36's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses of Heart Failure (a condition in which the heart doesn't pump as much blood as it should) and Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid).
Record review of the resident's Comprehensive Care Plan, dated 5/30/19 showed the following individual care plans:
-Mobility Care Plan showed:
--Required one to two person assistance with bed mobility and two-person assistance with all transfers for weight-bearing and safety;
--Used a wheelchair for mobility with assistance as needed;
--Used one-half upper side rails to reposition as desired with assistance from staff. The side rail intervention was hand written and there was no date showing when the intervention was added to the Mobility Care Plan;
-Potential for Falls Care Plan showed:
--Had muscle weakness;
--Needed a clutter-free environment;
--Required assistance with toileting, ambulation and mobility;
--Needed staff to observe for additional assistive and positioning devices as required;
--Needed the call light kept within reach.
Record review of the resident's 14-Day Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff for care planning purposes), dated 6/4/19, showed:
-Moderately cognitively impaired;
-Required extensive two person assistance with transfers;
-Was not steady and was only able to stabilize with assistance when:
--Moving from a seated to a standing position;
--Walking;
--Turning to face the opposite direction;
--Moving on and off the toilet;
--Transferring from surface to surface such as between a bed and a wheelchair;
-Had functional limitations impairments in range of motion (ROM - full movement potential of a joint) of Upper Extremities (UE - shoulder elbow, wrist and hand) and Lower Extremities (LE - hips, knee, ankle and feet);
-Used a walker and wheelchair;
-Had one non-injury fall since the previous assessment of 5/28/18;
-Received Occupational Therapy (OT - therapy based on engagement in meaningful activities of daily life such as self-help skills) five days a week;
-Received Physical Therapy (PT - non-pharmacological therapy for the preservation, enhancement or restoration of movement).
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/13/19, showed:
-The resident required two-person extensive assistance with transfers and had BLE (bilateral lower extremity) edema (swelling), pitting (indentations of the skin, associated with swelling) of the legs and his/her Lower Left Extremity (LLE) had decreased movement;
-A note written on the back of the form at 2:00 P.M. documented the following:
--The resident complained of left leg pain and received as needed (PRN) pain medication earlier that morning and had pain relief;
--The resident continued to work with Therapies and ambulated up to 40 feet with his/her roller walker with minimum to moderate assistance;
--The resident is on maximum assistance status with transfers;
--The resident wears TED (Thrombotic Embolic Deterrent - prevents blood clots) hose (compression stockings that help increase circulation to the lower legs) for swelling in BLEs;
-A note written at 3:30 P.M. documented the following:
--A fax was sent to the resident's Primary Care Physician (PCP) per resident and family request;
--The fax requested an order for an X-ray of the left ankle due to complaints of pain and increased swelling to the site. Staff were awaiting a response from the PCP;
--The resident was assisted by two staff members into bed;
--The resident's TED hose were removed from BLEs due to swelling and BLEs were elevated on pillows;
--The resident said his/her leg possibly twisted during an earlier transfer;
--Staff are unsure of the exact incident occurrence;
--Bruising was observed to the resident's ankle;
--The resident was to be checked on frequently for needs and concerns.
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/14/19 showed the resident needed one-person limited assistance with transfers, had an unsteady gait and decreased movement in the Right Lower Extremity (RLE) and LLE;
-There was no documentation on the back of the form on the Day shift;
-The 11:00 P.M. to 7:00 A.M. shift documented the following:
--The resident was in bed asleep with no outward signs of pain or discomfort noted;
--There was no documentation of edema noted;
--The resident is turned every two hours;
-Further review showed no documentation of a response from the physician regarding the request for an x-ray.
Record review of the resident's Daily Skilled Nurses' Notes, dated 6/15/19, showed:
-The resident needed two-person extensive assistance for transfers;
-The resident had BLE edema and pitting and an unsteady gait;
The resident had decreased movement in his/her LLE;
-A note written on the back of the form by the 7:00 A.M. to 7:00 P.M. shift showed:
--The resident is complaining of LLE pain which was noted to be tender to the touch;
--The resident worked with Therapy in the morning;
--New orders were obtained for Medrol dose pack, an X-ray of the left ankle and a one-time order for Colchicine (an anti-inflammatory) 0.6 milligram (mg);
--The nurse spoke with the family;
-Night shift Nurses' Notes showed at 10:30 P.M. the resident's X-ray report was received;
--The on-call physician was contacted and notified of the resident's X-ray results;
--The physician gave orders for the resident to be transferred to the emergency room (ER) for evaluation and treatment;
--Tramadol (treats moderate to severe pain), 50 mg was administered;
--The resident's DPOA was notified;
--Emergency Medical Services transported the resident to the acute care hospital at 11:20 P.M.
Record review of the resident's Incident Report and Investigation, dated 6/15/19, showed:
-An investigation summary which showed the following:
--The resident's left leg pain was assessed on 6/13/19 after the resident complained of pain to the area;
--The resident walked with Therapy staff prior to complaining of pain;
--After the resident complained of pain, slight edema was observed to BLEs which was normal for the resident;
--The resident said he/she got his/her foot tangled up during a transfer;
--The resident wore TED hose and had a history of gout (a form of arthritis (joint disorder) characterized by pain, redness and tenderness);
-The Incident Report showed an incident date of 6/15/19 when the left ankle fracture was identified;
--The on-call physician was notified on 6/15/19 at 2:00 P.M. and the Durable Power of Attorney (DPOA -gives a trusted person, chosen in advance, the legal right to make decisions and/or take care of financial affairs should a person become incapacitated and unable to act on their own behalf) was notified on 6/15/19 at 8:00 P.M.;
--Physician orders were received on 6/15/19 for Medrol dose pack (suppresses inflammation); X-ray of the left ankle, Colchicine 0.6 mg one time dose and transfer to the emergency room (ER);
--The X-ray of 6/15/19 showed a fractured ankle and the resident was sent to the emergency room that night;
Record review of the resident's Physician Orders, dated 6/2019, showed orders for:
-Stat (Latin statum, meaning urgent or rush) X-ray of left ankle due to pain, dated 6/15/19;
-Medro dose pack for wheezing and pain as directed, start date of 6/15/19;
-Colchicine 0.6 mg one time dose on 6/15/19 for Gout; and
-Send to ER on [DATE] to evaluate and treat for left ankle fracture.
Record review of the resident's Comprehensive Care Plan, dated 5/30/19, showed:
A Fracture Care Plan was added on 6/15/19 which showed the resident:
-Had a fracture of the Left Ankle Bimalleolar (a major ankle injury that involves breaks in two bones, the lateral and medial malleolus (prominence on the outer and inner side of the ankle) and was non-weightbearing (NWB);
-Had the following interventions:
--Monitor placement of the resident's left foot during two-person transfers;
--Keep the resident's family informed of appointments and findings;
--Elevate the resident's leg to reduce swelling;
--Assist the resident with repositioning;
--Assess the resident for edema.
Record review of the resident's Radiology Report, dated 6/16/19, showed:
-The resident was diagnosed with Bimalleolar fracture of the left ankle at the lower end of the fibula and the medial Malleolus (prominence on the inner side of the ankle) at the lower end of the tibia. The fibula and tibia are the two bones in the shin (calf of the leg);
-The resident had a follow-up orthopedic appointment on 6/19/19 at 2:30 P.M.
Record review of the Nurses' Notes, dated 6/16/19, showed:
-The resident returned to the facility from the ER at 9:45 A.M. with a diagnosis of Bimalleolar fracture of the left ankle;
-The resident complained of left ankle pain. PRN pain medications were administered twice during the 7:00 A.M. to 7:00 P.M. shift;
-The left ankle was splinted and wrapped by the ER;
-Two-person mechanical lift transfers were initiated.
During an interview on 6/24/19 at 8:52 A.M., the resident said:
-He/She got his/her left foot caught in the side rail while staff were putting him/her to bed one night approximately a week ago;
-He/She didn't know the name of the staff person who put him/her to bed but said he/she hadn't seen the person since the injury;
-One staff person was transferring him/her before the accident and since the accident they are using a mechanical lift and two staff members.
During an interview on 6/26/19 at 10:12 A.M. Licensed Practical Nurse (LPN) D said:
-After therapy worked with the resident he/she was weaker during transfers;
-He/She heard the accident happened either when getting up or while going to bed.
During an interview on 6/26/19 at 5:56 A.M. LPN G said:
-He/She was not working the night the resident was injured, but heard the resident got his/her foot caught in the rail;
-He/She thought it happened either the night of 6/12/19 or 6/13/19;
-He/She was working the night of 6/15/19 when the resident went to the hospital;
-The Day shift nurse got the order for the stat X-ray and the Night shift got the results of the X-ray by fax around 9:30 or 10:00 P.M.;
-A copy of the X-ray report was sent to the ER with the resident.
During an interview on 6/26/19 at 6:29 A.M. Certified Medication Technician (CMT) A said:
-Before the resident's accident, he/she was a one to two person transfer, depending on who was caring for him/her; and
-If staff tells the resident what they want him/her to do, the resident does well with following step by step instructions for transfers.
During an interview on 6/26/19 at 9:02 A.M., Certified Nurse Aide (CNA) G said:
-He/She transferred the resident into bed either on 6/13/19 or 6/14/19 at around 2:00 P.M. by himself/herself with a gait belt. He/She thought it was 6/14/19;
-It was a very good transfer with no twisting of the resident's feet. The resident didn't seem to be any weaker than normal;
-CNA C and LPN A were also working that day;
-That evening in the dining room at supper the resident complained of his/her foot hurting.
During an interview on 6/26/19 at 11:06 A.M. LPN C said:
-He/She just learned the resident was on mechanical lift status due to a fracture ankle;
-If a resident complains of pain the nurse is supposed to assess the area and look for swelling, send a fax to the physician and call the resident's family contact;
-If he/she didn't hear back from the physician within 24 hours he/she would call the physician.
During an interview on 6/26/19 at 11:14 P.M. the Director of Nursing (DON) said:
-The resident complained of left foot pain on 6/13/19 and told him/her it was from a transfer. The resident couldn't tell him/her if it was from his/her wheelchair into his/her bed or from the bed into the wheelchair;
-The resident received pain medication at 9:45 A.M. on 6/13/19 for left foot pain;
-The foot didn't look out of ordinary. It was swollen, but the resident has swelling;
-The resident had gout which causes pain;
-The resident went to Therapy earlier that day.
During an interview on 6/26/19 at 11:28 A.M. CNA C said:
-He/She transferred the resident off of the toilet and into his/her wheelchair on 6/13/19 around 10:45 A.M. Either CNA G or LPN A took the resident to the toilet;
-The resident complained of his/her left ankle hurting during the transfer. He/She stood up and transferred and put most of his/her weight on his/her right leg. He/She held onto the resident's gait belt and he/she sat down smoothly;
-He/She told LPN A about the resident's left foot pain;
-Before the transfer the resident transferred with one staff and a gait belt and since the accident has transferred with a mechanical lift.
During an interview on 6/26/19 at 4:10 P.M., the DON and Corporate Nurse said:
-If the nurse does not get a response from the physician, the nurse should try again that night to reach the PCP;
-On 6/13/19 in the afternoon LPN A faxed in the request for the X-ray. There was no response and staff called the on-call physician that weekend to get the order;
-He/She was unsure if the nurse did anything different for the resident after the change in condition occurred;
-He/She was not at the facility on 6/14/19 and 6/15/19, so he/she was unaware of any pain changes.
During an interview on 6/26/19 at 4:35 P.M. LPN A said:
-If a physician did not respond to a fax he/she would call the physician the next morning. If there was no answer he/she would try to get a hold of the on-call physician.
-He/She couldn't remember the resident ever asking for much pain medication;
-On 6/13/19 he/she remembered the resident received a dose of pain medication at 9:45 A.M.;
-The resident was only having pain with movement and touch. Once the resident was repositioned in bed the pain subsided;
-He/She expected the resident's pain would be different from that of gout, but the resident did not verbalize a description of the pain.
During a telephone interview on 6/26/19 at 5:47 P.M., the Medical Director said:
-The facility made him/her aware on 6/15/19 that the request for the order was faxed to the resident's PCP on 6/13/19;
-Since he/she was the Medical Director he/she should have been contacted if the facility could not get a hold of the resident's PCP.
During a telephone interview on 6/27/19 at 8:45 P.M. the resident's family member said:
-He/She saw the resident on 6/12/19 in the mid-afternoon and there were no visible signs of injury to the left foot or complaints of pain;
-When the DPOA visited the resident on 6/13/19 at 3:00 P.M., he/she noticed immediately the resident's foot was big and fat within his/her shoe. That amount of swelling was not normal for the resident. He/She had never seen the resident's legs so swollen when he/she was wearing his/her compression socks and swelling had never been localized to just one foot when they were swollen;
-The resident wore compression socks due to his her Venous Stenosis (wounds on the legs due to improper functioning of the valves of the veins (part of the circulatory system, carrying blood toward the heart);
-The resident's compression stocking had not been taken off and his/her foot was very swollen within his/her shoe;
-The resident told him/her the accident happened the night before when they were putting him/her to bed, but couldn't say who put him/her to bed. His/Her foot got caught and the resident pointed to the bed rail, but did not say how his/her foot came to hit or get caught in the bedrail;
-He/She suggested staff wrap and elevate the resident's foot to help keep the swelling down;
-He/She went out of the resident's room and told an LPN whose name he/she couldn't remember that the resident's foot was very swollen;
-The LPN told him/her the Day shift reported the resident was complaining of aches and pains to his/her foot, but did not say how long the resident had been complaining of pain;
-On 6/13/19 the facility made a call to the resident's PCP;
-He/She suggested the nursing staff put the resident to bed in an effort to help keep his/her foot elevated;
-He/She did not see the resident on 6/14/19;
-On 6/15/19 when he/she visited the resident his/her foot was still very swollen within his/her shoe. It was not elevated or wrapped and felt hard to the touch;
-The resident had guarded pain and winced and said the foot hurt when he/she moved it;
-He/She asked a nurse whose name he/she didn't remember if the facility ever got the resident's X-ray. The LPN responded they had not and asked if he/she wanted him/her to try again to reach the resident's physician. He/She told the LPN to try again to reach the physician. An on-call physician was working on 6/15/19;
-On 6/15/19 the facility staff did not say if they had attempted to contact the physician between 6/13/19 and 6/15/19
-An X-ray was done at the facility which looked positive for a fracture so the facility sent the resident to the hospital for more definitive images of the ankle; and
-The facility could have iced the area, put a compression bandage on it and ordered an X-ray right away.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
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, the facility failed to ensure alterative interventions were attempted before ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure alterative interventions were attempted before using side rails, failed to review risks and benefits of side rails with the resident and/or resident representative, and failed to conduct a side rail assessment for appropriateness for one sampled resident (Resident #39) out of 12 sampled residents. The facility census was 41 residents.
Record review of the facility's Side Rail Policy, unsigned and dated December 2016, showed:
-An assessment will be made to determine the resident's symptoms, risk of entrapment and reasons for using side rails, including:
--Bed mobility;
--Ability to change positions, transfer to and from bed or chair, and to stand and toilet;
--Risk of entrapment from the use of side rails;
--That the bed's dimensions are appropriate for the resident's size and weight;
-The use of side rails as an assistive device will be addressed in the resident's care plan;
-Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol;
-Less restrictive interventions that will be incorporated in care planning include:
--Restorative care to enhance abilities to stand safely and to walk;
--A trapeze to increase mobility;
--Placing the bed lower to the floor and surrounding the bed with a soft mat;
--Using a device that monitors resident's attempts to arise;
-Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails;
-The risks and benefits of side rails will be considered for each resident;
-Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks;
-The resident will be checked periodically for safety relative to the side rails;
-Facility staff, in conjunction with the attending physician, will assess and document the resident's risk for injury due to neurological disorders (any disorder of the nervous system) or other medical conditions.
1. Record review of the resident # 39's face sheet showed, he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-Dementia (a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging);
-Muscle weakness;
-Difficulty walking;
-Lack of coordination.
Record review of the resident's Quarterly Minimum Data Set (MDS - a required, federally mandated assessment tool completed by facility staff for care planning), dated 3/7/19, showed:
-The resident was severely cognitively impaired;
-The resident required extensive assist from one staff member for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene.
Record review of the resident's Significant Change MDS, dated [DATE], showed:
-The resident was severely cognitively impaired;
-The resident required total assist from two to three staff members for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene.
Observation on 6/24/19 at 8:57 A.M., showed one half bed/side rails, in the raised position on both sides of the resident's bed.
Observation on 6/24/19 at 10:00 A.M., showed one half bed/side rails, in the raised position on both sides of the resident's bed.
Observation on 6/24/19 at 11:57 A.M., showed one half bed/side rails, in the raised position on both sides of the resident's bed.
Observation on 6/25/19 at 12:21 P.M., showed one half bed/side rails, in the raised position on both sides of the resident's bed.
Record review of the resident's medical record showed staff did not complete side rail or entrapment assessments, a signed consent form, or document failed attempts prior to the use of side rails.
During an interview on 6/24/19 at 1:00 P.M., the resident's Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) said:
-Hospice brought the bed with the bed/side rails attached;
-Unsure if an assessment had been done;
-He/She had not been educated regarding risks and benefits of the side rails;
-He/She did not sign a consent for the side rails.
During an interview on 6/25/19 at 2:01 P.M. Physical Therapist Assistant (PTA) A said:
-If on therapy, therapy usually assessed residents for use of side rails;
-After completion of the assessment, therapy would talk with the nurse;
-Residents used the bed/side rails as enablers;
-Nursing asks for the therapy department's recommendation;
-Therapy worked with residents and assessed them, however, there was no written documentation of the assessment;
-He/She felt like all hospice residents should have bed/side rails;
-Therapy did not work with hospice residents.
During an interview on 6/26/19 at 4:21 P.M. Licensed Practical Nurse (LPN) C said, he/she:
-Worked at the facility as needed (PRN);
-Helped out wherever needed;
-Knew the resident's name, but was not that familiar with the resident;
-Was unaware that staff needed to complete entrapment assessments or a side rail assessments;
-Was sure the resident and resident representative were educated regarding side rails and would be documented in the nurse's notes.
During an interview on 6/26/19 at 4:35 P.M. LPN A said, he/she:
-Was unsure of any assessments that needed to be done for side rails;
-Had never filled out any entrapment or side rail assessments before;
-Made sure there was a physician's order for side rails;
-Maintenance measured the gap between rail and mattress;
-Thought the following people reviewed the chart to ensure correct completion of the side rail assessment:
--The MDS coordinator;
--The head of Medical Records;
--The Director of Nursing (DON).
During an interview on 6/28/19 at 10:08 A.M. LPN B said:
-Must have an order from the physician for side rails;
-Side rails must be care planned;
-If ordered by hospice, he/she would talk with hospice regarding rationale of side rails;
-If the resident requested side rails he/she would:
--Do a visual assessment for side rails, he/she did not document assessment in the medical record;
--Talk with the resident as to why they want the side rails;
--Talk with the family regarding side rails; and
--Ensure other alternative interventions had been attempted first, (fall mats, low position bed,) not a lot of options;
--Explain risks and benefits of side rails to the resident and resident representative;
-If unsure why side rails were on a bed, he/she:
--Checked for an order;
--Investigated why the side rails were on the bed.
During an interview on 6/28/19 at 1:38 P.M.; the Director of Nursing (DON) said he/she expected:
-The nursing and/or Physical Therapy (PT) staff to conduct and document a side rail assessment;
-Documentation in the nurse's notes of all alternative interventions tried before instillation of the side rails;
-A discussion regarding the risks and benefits of side rails with the resident and resident representative;
-A signed side rail consent form in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure behavioral monitoring for one sampled resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure behavioral monitoring for one sampled resident (Resident #23) out of 12 sampled residents, who had sexually inappropriate behaviors and was on medication for the behaviors. The facility census was 41 residents.
Record review of the facility's Behavioral, Assessment, Intervention and Monitoring policy, revised 4/2019, showed:
-The facility would provide and residents would receive behavioral health services as needed;
-The interdisciplinary team would thoroughly evaluate new or changing behavioral symptoms in order to find underlying causes;
-The interdisciplinary team would evaluate behavioral symptoms to determine the degree of the symptoms, distress and potential safety risk to the resident, and develop a plan of care;
-Safety strategies would be implemented immediately if necessary to protect the resident and other residents from harm;
-The interdisciplinary team would document any altered behavior and would seek and document any worsening behaviors or improved behaviors;
-The interdisciplinary team would monitor the progress of the individual until stable.
1. Record review of Resident #23's Face Sheet showed the resident was admitted to the facility on [DATE] and did not have a diagnosis related to behaviors.
Record review of the resident's Care Plan Conference Summary, dated 11/7/18, showed there was no staff documentation related to behaviors.
Record review of the resident's Nurse's Notes, dated 12/2/19, showed:
-It was reported to this nurse the resident was outside and had his/her private parts exposed in front of other residents;
-He/She discussed the inappropriate behavior with the resident and reported the behavior to the Director of Nursing (DON).
Record review of the resident's Nurse's Notes, dated 1/9/19, showed:
-The resident's physician was in the building and gave orders for Depo Provera (a hormone medication that reduces sexual tendencies) 150 milligrams (mg) every 90 days;
-There was no documentation that showed what the medication was for.
Record review of the resident's Telephone Orders Sheet (TOS), dated 1/9/19, showed the following physician's order: Depo Provera 150 mg injection every 90 days.
Record review of the resident's Physician's Orders Sheet (POS), dated 1/2019, showed the following physician's order: Depo Provera 150 mg injection every 90 days for sexual aggression.
Record review of the resident's Care Plan, dated 1/10/19, showed:
-The resident had the potential to display sexually inappropriate behaviors at times;
-The staff were to document the behaviors as they occur;
-The staff were not to argue with him/her, but give simple education why the behavior was not appropriate;
-The staff were to administer the medication for the behavior per the physician's orders.
Record review of the resident's Medication Administration Record (MAR), dated 1/2019, showed the Depo Provera 150 mg injection was administered to the resident on 1/13/19.
Record review of the resident's Care Plan Conference Summary, dated 1/30/19, showed there was no staff documentation related to behaviors.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning), dated 1/30/19, showed the resident:
-Was moderately cognitively impaired;
-Did not have behaviors;
-Needed limited assistance with walking.
Record review of the resident's Medication Administration Record (MAR), dated 4/2019, showed the Depo Provera 150 mg injection was administered to the resident on 4/13/19.
Record review of the resident's Care Plan Conference Summary, dated 4/24/19, showed there was no staff documentation related to behaviors.
Record review of the resident's Physicians progress notes, dated 4/30/19, showed:
-The resident was being treated with Depo Provera for sexual inappropriateness since 1/2019;
-The medication seemed to be effective and the resident did not have any side effects from the medication.
Record review of the resident's medical record on 6/27/19 showed there was no further documentation related to the resident's sexually inappropriate behaviors and no behavioral monitoring system.
During an interview on 6/26/19 at 6:26 A.M., Certified Nursing Assistant (CNA) E said:
-The resident said sexually inappropriate words towards his/her co-worker;
-The resident would go outside and he/she would catch the resident trying to look at female residents through outside windows;
-He/She would tell the resident to get away from the window;
-The resident did not try to touch the residents or staff;
-He/She always reported these incidents to the charge nurse;
-He/She had not seen these types of behaviors since around December.
During an interview on 6/26/19 at 10:39 A.M., CNA F said:
-The resident had sexually inappropriate behaviors;
-When the resident would come out of his/her room he/she come out of his/her room, but would touch his/her private parts over his/her clothing while going down the hall;
-This behavior stopped for a while, but he/she noticed the behavior was back but not as bad as it used to be;
-He/She would tell the resident this behavior was not appropriate and then let the charge nurse know;
-Before, the resident exhibited these behaviors every night when he/she worked the evening/night shift;
-Now these behaviors were happening once or twice a week;
-The resident did not try to touch other residents inappropriately;
-CNAs did not document on behaviors;
-The charge nurse was responsible for documenting behaviors;
-He/She reported the behaviors to the charge nurses.
During an interview on 6/26/19 at 11:06 A.M., Licensed Practical Nurse (LPN) C said:
-The resident did have inappropriate behaviors;
-The resident grabbed his/her buttocks two times in one day;
-The resident had said sexually inappropriate comments to him/her;
-He/She educated the resident and told him/her these behaviors were inappropriate;
-The nurses were responsible for tracking behaviors on a behavioral flow sheet;
-He/She had not been documenting the resident's behaviors in the medical record, but should have;
-He/She did not remember seeing a behavioral flow sheet in the resident's medical record;
-He/She was unsure who would start a behavioral flow sheet if a resident started having behaviors.
Observation on 6/26/19 at 10:56 A.M. showed the resident was in his/her room lying in bed and was not exhibiting any sexually inappropriate behaviors.
Observation on 6/28/19 at 9:47 A.M. showed the resident:
-Was in his/her wheelchair in the hallway;
-Was not exhibiting any sexually inappropriate behaviors.
During an interview on 6/28/19 at 1:38 P.M. the Director of Nursing (DON) said:
-The nurses should have been charting on the behaviors in the nurses notes and the nurses could also start a behavioral flow sheet to monitor the resident's behaviors;
-The resident would touch himself/herself with no clothing on in the courtyard;
-This behavior should be done in his/her room alone;
-The resident did not say anything directly sexually inappropriate to him/her, but did say inappropriate things of a sexual nature to the staff;
-The resident did have sexually inappropriate behaviors since the Depo Provera was started;
-The resident's behaviors should have been monitored.
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** Based on observation, interview and record review, the facility failed to ensure infection control best practices were used for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control best practices were used for oxygen tubing when in use or stored for two sampled residents (Resident #4 and #16) out of 12 sampled residents. The facility census was 41 residents.
1. Record review of Resident #4's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnosis: anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning), dated 7/8/18, showed the resident was moderately cognitively impaired.
Record review of the resident's Care Plan, updated on 4/5/19, showed the resident:
-Was only alert and oriented to himself/herself only;
-Used oxygen as needed.
Observation on 6/24/19 at 9:47 A.M., showed:
-The resident was in his/her wheelchair in his/her room;
-The resident's oxygen concentrator was on and the resident was wearing the nasal cannula;
-The resident's oxygen tubing was on the floor.
Observation on 6/25/19 at 8:14 A.M., showed the resident's oxygen tubing was coiled up, not bagged, and lying on the oxygen concentrator.
Observation on 6/26/19 at 10:53 A.M., showed:
-The resident was in his/her wheelchair in his/her room;
-The resident's oxygen concentrator was on and the resident was wearing the nasal cannula;
-The resident's oxygen tubing was on the floor.
2. Record review of Resident #16's Face Sheet showed the resident was admitted to the facility on [DATE] with a diagnoses of dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behavioral disturbances.
Record review of the resident's admission MDS, dated [DATE], showed the resident was severely cognitively impaired.
Record review of the resident's care plan, dated 4/30/19, showed the resident used oxygen therapy as needed.
Observation on 6/24/19 at 9:37 A.M. and at 11:06 A.M., showed:
-The resident was asleep in his/her bed;
-The resident had oxygen on running at 2 liters via nasal cannula;
-The resident's oxygen tubing was on the floor.
During an interview on 6/26/19 at 10:26 A.M. Certified Nursing Assistant (CNA) B said:
-The CNAs were responsible for ensuring the residents' oxygen tubing was stored in plastic bags when not in use;
-When a resident was using his/her oxygen, the tubing should not be on the floor.
During an interview on 6/28/18 at 9:22 A.M., Licensed Practical Nurse (LPN) B said:
-The CNAs were responsible for putting the residents' oxygen tubing in a plastic bag when not in use;
-The CNAs were responsible for ensuring the resident's oxygen tubing was not on the floor when in use.
During an interview on 6/28/19 at 1:38 P.M. the Director of Nursing (DON) said:
-The CNAs were responsible for storing the residents' oxygen tubing in a plastic bag when not in use;
-The CNAs should ensure the resident's oxygen tubing was not on the floor when in use.
A policy was requested but not received by 7/10/19.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure residents had the opportunity to consistently receive mail and packages that were delivered to the facility on Saturdays for residen...
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Based on interview and record review, the facility failed to ensure residents had the opportunity to consistently receive mail and packages that were delivered to the facility on Saturdays for residents who receive personal mail. The facility census was 41 residents.
Record review of the United State Postal Service (USPS) website showed mail was delivered to the community Monday through Saturday.
1. During a group interview on 6/25/19 at 10:33 A.M., during the resident council group meeting, eight residents said:
-The postal worker delivered the mail to the facility and the mail was placed in the front office area computer room in a container on the floor on Saturdays;
-They did not want the mail left unattended in the front office, because anyone could walk in and take their mail;
-The staff did not deliver the mail on Saturday to the residents;
-The residents did not get their Saturday mail until Monday.
During an interview on 6/28/19 at 10:34 A.M., the Administrative Assistant said:
-He/She received the resident's mail Monday through Friday;
-He/She delivered the mail to the residents during the week;
-On Saturday, the postal worker delivered the mail to the nurses' station;
-He/She had asked the nurses to sort and deliver Saturday mail to the residents;
-Some nurses do not feel comfortable sorting through the mail and delivering it to the residents;
-The nurses would lock the mail in the medication room until Monday and he/she would distribute the Saturday mail to the residents on Monday.
During an interview on 6/28/19 at 1:35 P.M., the Director of Nursing (DON) said:
-He/She expected the nurses to deliver the mail to the resident's on Saturday;
-An in-service regarding Saturday mail delivery had been given to the staff within the last year regarding Saturday mail delivery.
A policy was requested from the facility and was not received by 7/11/19.
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?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Missouri facilities.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s). Review inspection reports carefully.
- • 50 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (18/100). Below average facility with significant concerns.
Bottom line: Trust Score of 18/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Ridge Crest Nursing Center's CMS Rating?
CMS assigns RIDGE CREST NURSING CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Ridge Crest Nursing Center Staffed?
CMS rates RIDGE CREST NURSING CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Ridge Crest Nursing Center?
State health inspectors documented 50 deficiencies at RIDGE CREST NURSING CENTER during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 47 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Ridge Crest Nursing Center?
RIDGE CREST NURSING CENTER 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 CIRCLE B ENTERPRISES, a chain that manages multiple nursing homes. With 120 certified beds and approximately 42 residents (about 35% occupancy), it is a mid-sized facility located in WARRENSBURG, Missouri.
How Does Ridge Crest Nursing Center Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, RIDGE CREST NURSING CENTER's overall rating (1 stars) is below the state average of 2.5 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Ridge Crest Nursing Center?
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?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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 below-average staffing rating.
Is Ridge Crest Nursing Center Safe?
Based on CMS inspection data, RIDGE CREST NURSING CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Ridge Crest Nursing Center Stick Around?
RIDGE CREST NURSING CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Ridge Crest Nursing Center Ever Fined?
RIDGE CREST NURSING CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Ridge Crest Nursing Center on Any Federal Watch List?
RIDGE CREST NURSING CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.