THE LAURELS OF WILLOW CREEK
For profit - Corporation
120 Beds
CIENA HEALTHCARE/LAUREL HEALTH CARE
Data: November 2025
Trust Grade
40/100
#228 of 285 in VA
Photo by Laurels of Willow Creek
Photo by Laurels of Willow Creek
Photo by Laurels of Willow Creek
1 / 5 photos
Last Inspection: September 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
The Laurels of Willow Creek has a Trust Grade of D, which indicates below average performance with some serious concerns. It ranks #228 out of 285 nursing homes in Virginia, placing it in the bottom half of facilities statewide, and #4 out of 6 in Chesterfield County, meaning only two local options are worse. The facility's trend is worsening, with the number of reported issues increasing from 17 in 2022 to 18 in 2023. Staffing is rated as average, with a 3/5 star rating and a turnover rate of 45%, which is slightly better than the state average. However, the facility has concerning RN coverage, being less than 88% of Virginia facilities, which could impact the quality of care. Specific incidents reported include a serious medication error where a resident was overdosed on Methadone, resulting in a dangerous drop in oxygen levels and requiring hospitalization. Additionally, staff failed to administer the correct dosage of the COVID-19 vaccine to another resident, though there were no adverse outcomes. There were also findings related to unsanitary food storage practices in the kitchen, which raises concerns about overall hygiene and care standards. While there are some strengths, such as no fines on record, families should weigh these serious issues when considering this facility for their loved ones.
- Trust Score
- D
- In Virginia
- #228/285
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Virginia facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 20%
Needs review
17 → 18 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 17 issues
2023: 18 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Virginia average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 45%
Near Virginia avg (46%)
Higher turnover may affect care consistency
Chain: CIENA HEALTHCARE/LAUREL HEALTH CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 54 deficiencies on record
2 actual harm
Sept 2023
18 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
Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to promote dignity for one of 37 residents, Resident #24.
The findin...
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Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to promote dignity for one of 37 residents, Resident #24.
The findings include:
For Resident #24 (R24), the facility staff failed to uphold the resident's dignity due to not providing timely incontinence care.
R24 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and abnormalities of gait and mobility.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/20/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating R24 was moderately impaired of cognition for making daily decisions. Under Section H Bladder and Bowel R24 was coded as being always incontinent of urine.
On 09/11/23 at 12:35 p.m., an observation revealed that R24, who resided on the west unit at the facility, activated the call bell for incontinence care.
On 09/11/23 at 12:45 p.m., an observation revealed CNA (certified nursing assistant) #2 entered R24's room, turned off the call and left the room with R24's lunch tray.
On 09/11/2023 at 1:00 p.m., an observation revealed LPN (licensed practical nurse) #4 entered R24's room and provided incontinence care.
On 09/12/23 at approximately 1:06 p.m., an interview was conducted with CNA (certified nursing assistant) #2.
When asked about her entering R24's room at approximately 12:45 p.m., the day before, she stated that she picked up R24's meal tray and that R24 asked if she would clean her up. CNA #2 stated that she told R24 that when she finished picking up the meal trays she would come back and provide incontinence care. When asked what time she finished picking up the meal trays, CNA #2 stated that it was after 1:00 p.m. but could not recall the exact time. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that it should be done right away so the resident is not sitting in a soiled brief. When asked if R24's was on their assignment for Monday 9/11/2023, she stated yes. When informed of the above observations and that R24 waited approximately 25 minutes to receive incontinence care after activating her call bell and informing CNA #2, CNA #2 stated that she could have notified the nurse that R24 required incontinence care. When asked if it is dignified to have a resident wait in a soiled brief for approximately 25 minutes, she stated no.
On 09/12/23 at approximately 1:33 p.m., an interview was conducted with LPN (licensed practical nurse) #2, unit manager. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that the resident should only have to wait within 15 to 20 minutes. When informed of the above observations LPN #2 stated that the CNA should have let the nurse know R24 required incontinence care. When asked if it is dignified to have a resident wait in a soiled brief for approximately 25 minutes, she stated no.
On 09/12/23 at approximately 1:53 p.m., an interview was conducted with LPN #4, MDS nurse. When asked if she entered R24's room on Monday, 09/11/2023 at approximately 1:00 p.m., she stated yes. When asked about providing incontinence care to R24, LPN #4 stated that she provided incontinence care, and that the resident was wet. LPN #4 further stated that she was not aware that R24 had been waiting for incontinence care because she had just walked onto the unit. When asked if it is dignified to have a resident wait in a soiled brief for approximately 25 minutes, she stated no.
On 09/13/2023 at approximately 1:00 p.m., an interview was attempted with R24. When asked how she felt being left in a wet brief when she did not receive incontinence care when she asked for assistance, R24 stated that she did not want to speak to the surveyor.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
2. For Resident #87 (R87), the facility staff failed to notify the physician when the medication levothyroxine sodium (1) was not available for administration on 9/10/23 and 9/11/23.
A review of R87's...
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2. For Resident #87 (R87), the facility staff failed to notify the physician when the medication levothyroxine sodium (1) was not available for administration on 9/10/23 and 9/11/23.
A review of R87's clinical record revealed a physician's order dated 9/6/23 for levothyroxine sodium 75 mcg (micrograms)- one tablet by mouth in the morning for hypothyroidism. A review of R87's September 2023 MAR (medication administration record) revealed the same physician's order for levothyroxine sodium. On 9/10/23 and 9/11/23, the MAR documented the code, 5=Hold/See Nurse Notes. Nurses' notes dated 9/10/23 and 9/11/23 documented the medication was not available in the medication cart. Further review of nurses' notes and the September 2023 MAR failed to reveal documentation that levothyroxine sodium was administered to R87 on 9/10/23 and 9/11/23 and failed to reveal documentation that R87's physician was notified.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the physician should be notified when a medication is not available for administration because sometimes the physician can give another order.
On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
Reference:
(1) Levothyroxine is used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682461.html
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician medications not ordered and/or administered, for two of 37 residents in the survey sample, Resident #225 and Resident #87.
The findings include:
1. For Resident #225 (R225), the facility staff failed to notify the physician when a medication, for the treatment of urinary retention, from a consulting physician was ordered.
R225 was admitted with diagnoses that included but were not limited to benign prostatic hyperplasia (1).
A urology office visit note for R225 documented in part, 11/25/2022 - Office visit: General. The patient was accompanied by his son . Under Prescription(s) Today it documented in part, Dutasteride (2) 0.5 mg (milligram) capsule (dutasteride) Take 1 (one) capsule by mouth as directed at 9 am (9:00 a.m.) daily. Under Plan it documented in part, We had a discussion regarding addition of 5-alpha reductase inhibitor (3) .
The prescription slip from the urologist dated 11/25/2022 at 3:58 p.m. documented in part, Dutasteride 0.5 mg capsule. Dispense 30 (thirty) capsules. Take (one) capsule by mouth as directed at 9 AM daily.
The facility physician's order for R225 documented in part, Dutasteride Capsule 0.5 MG. Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia. Order Date: 11/28/2022.
The eMAR (electronic medication administration record) for R225 dated November 2022 revealed the first dose of Dutasteride wasn't administered until 11/28/2022.
The nurse practitioner's (NP) note for R225 dated 11/28/2022 at 1:53 p.m., documented in part, A/P (assessment/plan) . Dutasteride added 11/28 .
Review of the facility's nursing progress notes dated 11/25/2022 through 11/27/2022 failed to evidence documentation of notification to the physician or NP of R225 consulting physician's order.
On 09/12/2023 at approximately 3:43 p.m., an interview was conducted with LPN (licensed practical nurse) #8. When asked to describe the procedure when a resident brings in a prescription for a medication from a provider outside of the facility she stated that the nurse should put order in computer, talk to the physician or NP if they are in the building or call them to let them know the resident has a new prescription, put the script in the doctors book and call the pharmacy if the medication is not available in the facility. When asked if they recalled R225 and when R225's son brought him back to the facility from a urology appointment on 11/25/2022 she stated yes. LPN #8 stated that R225 and his son came back from an appointment between 7:00 p.m. and 8:00 p.m. with a prescription for urinary retention. LPN #8 further stated she did not call the physician.
On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. When asked about R225 not receiving Dutasteride when it was ordered by the urologist, ASM #2 stated that the resident arrived around 8:00 p.m., the script was handed to the nurse and faxed it to the pharmacy but did not notify the on-call provider. She further stated that the NP was notified on the following Monday, 11/28/2022, and R225 received his first dose that day. When asked if there was a delay in R225 receiving his medication ASM #2 stated yes. When asked if the physician or NP was notified that R225 did not receive the medication of Dutasteride she stated no.
On 09/13/2023 at approximately 3:00 p.m., ASM (administrative staff member) #1, administrator, and ASM #2, director of nursing, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html.
(2) Used alone or with another medication (tamsulosin [Flomax]) to treat benign prostatic hyperplasia (BPH; enlargement of the prostate gland). May reduce the chance of developing acute urinary retention. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603001.html.
(3) A class of medication used in the management and treatment of benign prostatic hyperplasia (BPH). This information was obtained from the website: https://www.ncbi.nlm.nih.gov/
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promptly resolve a grievance for one of 37 residents in the survey sampl...
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Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promptly resolve a grievance for one of 37 residents in the survey sample, Resident #87.
The findings include:
For Resident #87 (R87), the facility staff failed to resolve the resident's grievance regarding her roommate.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.
On 9/11/23 at 2:48 p.m., an interview was conducted with the resident. R87 voiced concern that her roommate is often agitated, swears for hours and bangs on the snack table at different times throughout the day and night. R87 stated this has occurred since she moved into the room (on 8/1/23), her roommate keeps her up during the night, staff is aware, and no one has resolved this concern. At this time, R87's roommate was observed lying in bed and loudly speaking incoherent words.
A review of R87's clinical record (progress notes for August 2023 and September 2023) and grievance logs for August 2023 and September 2023 failed to reveal documentation regarding the resident's concern. Nurse practitioner notes dated 8/4/23, 8/6/23 and 9/1/23 documented R87 complained of not sleeping well.
On 9/12/23 at 12:50 p.m., an interview was conducted with LPN (licensed practical nurse) #2 (the unit manager). LPN #2 stated R87 has had complaints regarding her roommate and stated she's not getting any sleep. LPN #2 stated she spoke with R87's representative who agrees that the resident tends to say things that aren't true, and the nurses are reporting R87 is sleeping at night. LPN #2 stated she thought R87 wanted to be in a bed by the window, but the roommate didn't want to move, and no other room was available. LPN #2 stated she did not complete a grievance form regarding R87's concern but she spoke with the resident's representative on the previous day and the representative was happy with everything. When asked what has been done to ensure R87's grievance was resolved and the resident was satisfied, LPN #2 stated she has verified with nurses that the resident is sleeping.
On 9/12/23 at 5:11 p.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator and grievance officer). ASM #1 stated that anyone including residents, family members or staff can fill out a grievance form then the form is taken to the stand down or morning meetings and discussed. ASM #1 stated the grievance is then assigned to the appropriate discipline and those staff are responsible for investigating the grievance and developing a plan to try to resolve the grievance. ASM #1 stated that after this is done, staff is supposed to talk to the resident and determine if he or she is satisfied.
On 9/12/23 at 5:15 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Care Program documented, All concerns/grievances are investigated, resolved, and documented .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on staff interview and clinical record review it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 37 residents, Resident #103.
T...
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Based on staff interview and clinical record review it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 37 residents, Resident #103.
The findings include:
For Resident #103 (R103), the facility staff failed to code the discharge MDS assessment with an ARD (assessment reference date) of 7/3/2023 with the accurate discharge location.
On the most recent MDS, the discharge assessment with an ARD of 7/3/2023, the resident was coded as having an unplanned discharge to the community.
The progress notes for R103 documented in part,
- 7/3/2023 19:16 (7:16 p.m.) Note Text: went to check on guest while awaiting return call from on call [medical provider], guest now c/o (complains of) of pain in lower abdominal area, no specific site; rp (responsible party) in room insisting guest to be sent out, will let np (nurse practitioner) know family choice.
- 7/3/2023 19:52 (7:52 p.m.) Note Text: spoke with np told of change in condition and family request and agreed to transfer to hospital per rp request; rescue squad in transporting guest to (Name of hospital) accompanied by rp.
On 9/13/2023 at 8:41 a.m., an interview was conducted with RN (registered nurse) #2, MDS nurse. RN #2 stated that they had daily clinical meetings to discuss skilled residents, discuss discharges and unplanned discharges and reviewed the 24 hour reports to find out any residents who were discharged or transferred to the hospital. She reviewed R103's discharge MDS with the ARD of 7/3/2023 and the progress notes dated 7/3/2023 and stated that the MDS was not correct and should have been coded that they went to the hospital. She stated that the MDS needed to be corrected. She stated that they followed the RAI (resident assessment instrument) manual when completing the MDS assessments.
According to the RAI Manual, Version 1.16, dated October 2018, section A2100: OBRA Discharge Status, documented in part, Steps for Assessment: 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location .Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home . Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons .
On 9/13/2023 at 9:30 a.m., ASM (administrative staff member) #1, the administrator was made aware of the concern.
No further information was provided prior to exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for three of 37 residents in the survey sample, Re...
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Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for three of 37 residents in the survey sample, Residents #87, #55 and #225.
The findings include:
1. For Resident #87 (R87), the facility staff failed to administer the medication levothyroxine sodium (1) 75 mcg (micrograms) per physician's order on 9/10/23 and 9/11/23.
A review of R87's clinical record revealed a physician's order dated 9/6/23 for levothyroxine sodium 75 mcg- one tablet by mouth in the morning for hypothyroidism. A review of R87's September 2023 MAR (medication administration record) revealed the same physician's order for levothyroxine sodium. On 9/10/23 and 9/11/23, the MAR documented the code, 5=Hold/See Nurse Notes. Nurses' notes dated 9/10/23 and 9/11/23 documented the medication was not available in the medication cart. Further review of nurses' notes and the September 2023 MAR failed to reveal documentation that levothyroxine sodium was administered to R87 on 9/10/23 and 9/11/23.
A review of the facility backup medication supply list revealed levothyroxine sodium 75 mcg tablets were available in the supply.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated nurses should re-order medications from the pharmacy when there are five or six pills left. LPN #3 stated if a medication is not available for administration, the medication should be pulled from the backup medication supply, and if the medication is not available in the supply, then the nurses should call the pharmacy and ask for the medication to be sent STAT (immediately).
On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Medication Administration documented, Medications are administered in accordance with written orders of the attending physician.
Reference:
(1) Levothyroxine is used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682461.html.
2. For Resident #55 (R55), the facility staff failed to accurately transcribe a physician's order to administer the resident's potassium via PEG (percutaneous endoscopic gastrostomy) tube instead of via mouth.
A review of R55's clinical record revealed a physician's order dated 8/17/23 for, Nothing by Mouth diet, Nothing by Mouth texture, Nothing by Mouth consistency. Further review of R55's clinical record revealed a physician's order dated 8/18/23 for potassium chloride liquid 20 milliequivalents/15 milliliters- 20 milliequivalents by mouth three times a day.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated if a resident with a peg tube has a physician's order for nothing by mouth, then medications should be administered via peg, and the order should document that. LPN #3 stated that when the nurses put orders into the computer system, they get used to entering the route as by mouth and someone may have unintentionally entered the wrong route for R55's potassium.
Interviews were conducted with nurses who cared for R55. The nurses stated they administer the resident's medications via peg.
On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, The licensed nurse receiving the order must verify to ensure the order is complete and it includes: Accurate route .
3. For Resident #225 (R225), the facility staff failed to obtain a physician's order as prescribed by the consulting physician for the medication, Dutasteride (1), used for urinary retention.
R225 was admitted with diagnoses that included but were not limited to benign prostatic hyperplasia (2).
A urology office visit note for R225 documented in part, 11/25/2022 - Office visit: General. The patient was accompanied by his son . Under Prescription(s) Today it documented in part, Dutasteride (2) 0.5 mg (milligram) capsule (dutasteride) Tale 1 (one) capsule by mouth as directed at 9 am (9:00 a.m.) daily.
The prescription slip from the urologist for R225 dated 11/25/2022 at 3:58 p.m. documented in part, Dutasteride 0.5 mg capsule. Dispense 30 (thirty) capsules. Take (one) capsule by mouth as directed at 9 AM daily.
The facility physician's order for R225 documented in part, Dutasteride Capsule 0.5 MG. Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia. Order Date: 11/28/2022.
The eMAR (electronic medication administration record) for R225 dated November 2022 documented the physician's order as stated above, however the first dose of dutasteride wasn't administered until 11/28/2022.
The nurse practitioner's (NP) note for R225 dated 11/28/2022 at 1:53 p.m., documented in part, A/P (assessment/plan) . Dutasteride added 11/28 .
On 09/12/2023 at approximately 3:43 p.m., an interview was conducted with LPN (licensed practical nurse) #8. When asked to describe the procedure when a resident brings in a prescription for a medication from a provider outside of the facility she stated that the nurse should put order in computer, talk to the physician or NP if they are in the building or call them to let them know the resident has a new prescription, put the script in the doctors book and call the pharmacy if the medication is not available in the facility. When asked if they recalled R225 and when R225's son brought him back to the facility from a urology appointment on 11/25/2022 she stated yes. LPN #8 stated that R225 and his son came back from an appointment between 7:00 p.m. and 8:00 p.m. with a prescription for urinary retention. LPN #8 further stated she did not call the physician.
On 09/13/2023 at approximately 9:52 a.m., an interview was conducted with ASM (administrative staff member) #4, nurse practitioner. When asked to describe the procedure she follows when a resident receives a script for a prescription from a provider outside of the facility, she stated that the staff gives the scrip to her the day the resident receives it or the next morning. She further stated that if she were not in the facility the nurse would call the on-call provider. When asked if she recalled R225 and the order for Dutasteride she stated that she did and further stated that that staff could not locate the order and she had them call the pharmacy and verify the order on Monday (11/28/2023).
On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. When asked about R225 not receiving Dutasteride when it was ordered by the urologist ASM #2 stated that the resident arrived around 8:00 p.m., the script was handed to the nurse and faxed it to the pharmacy but did not notify the on-call provider. She further stated that the NP was notified on the following Monday, 11/28/2022, and R225 received his first dose that day. When asked if there was a delay in R225 receiving his medication ASM #2 stated yes.
The facility's grievance form for R225 dated 11/29/2022 documented in part, What is your concern about? Had urology appt (appointment) Friday and brought paperwork and prescription back. Handed to a nurse. Visited Monday morning and medication was not ordered. Concerned this is a setback. When did the problem occur? Friday 11/25/22. Facility Response: NP reached out to urologist and got new script and ordered medication. Action To Be Taken: Writer spoke with nurse. Nurse stated that she received the paperwork, faxed the prescription to the pharmacy and placed in the scan pile. She stated she did not put the order in PCC (point click care - electronic health record. Writer informed nurse that paperwork is to be placed in the MD (medical doctor) book and order put in PCC.
On 09/13/2023 at approximately 3:00 p.m., ASM (administrative staff member) #1, administrator, and ASM #2, director of nursing, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Used alone or with another medication (tamsulosin [Flomax]) to treat benign prostatic hyperplasia (BPH; enlargement of the prostate gland). May reduce the chance of developing acute urinary retention. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603001.html.
(2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html.
(3) A class of medication used in the management and treatment of benign prostatic hyperplasia (BPH). This information was obtained from the website: https://www.ncbi.nlm.nih.gov/
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) for one of 37 residents,...
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Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) for one of 37 residents, Resident #24.
The findings include:
For Resident #24 (R24), the facility staff failed to provide timely incontinence care.
R24 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and abnormalities of gait and mobility.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/20/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating R24 was moderately impaired of cognition for making daily decisions. Under Section H Bladder and Bowel R24 was coded as being always incontinent of urine.
On 09/11/23 at 12:35 p.m., an observation revealed that R24 activated the call bell for incontinence care.
On 09/11/23 at 12:45 p.m., an observation revealed CNA (certified nursing assistant) #2 entered R24's room, turned off the call and left the room with R24's lunch tray.
On 09/11/2023 at 1:00 p.m., an observation revealed LPN (licensed practical nurse) #4 entered R24's room and provided incontinence care.
On 09/12/23 at approximately 1:06 p.m., an interview was conducted with CNA (certified nursing assistant) #2. When asked about her entering R24's room at approximately 12:45 p.m., the day before, she stated that she picked up R24's meal tray and that R24 asked if she would clean her up. CNA #2 stated that she told R24 that when she finished picking up the meal trays she would come back and provide incontinence care. When asked what time she finished picking up the meal trays, CNA #2 stated that it was after 1:00 p.m. but could not recall the exact time. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that it should be done right away so the resident is not sitting in a soiled brief. When asked if R24's was on their assignment for Monday 0-9/11/2023, she stated yes. When informed of the above observations and that R24 waited approximately 25 minutes to receive incontinence care after activating her call bell and informing CNA #2, CNA #2 stated that she could have notified the nurse that R24 required incontinence care.
On 09/12/23 at approximately 1:33 p.m., an interview was conducted with LPN (licensed practical nurse) #2, unit manager. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that the resident should only have to wait within 15 to 20 minutes. When informed of the above observations LPN #2 stated that the CNA should have let the nurse know R24 required incontinence care.
On 09/12/23 at approximately 1:53 p.m., an interview was conducted with LPN #4, MDS nurse. When asked if she entered R24's room on Monday, 09/11/2023 at approximately 1:00 p.m., she stated yes. When asked about providing incontinence care to R24, LPN #4 stated that she provided incontinence care, and that the resident was wet. LPN #4 further stated that she was not aware that R24 had been waiting for incontinence care because she had just walked onto the unit.
The facility's policy Routine Resident Care it documented in part, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Under Guidelines to documented in part, 8. Incontinence care is provided timely according to each resident's needs.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for the treatment of pressure injuries for one of 37 residents in the survey sample; Resident #205.
The findings include:
The facility policy, Skin Management was reviewed. This policy documented, Upon admission/re-admission all guests/residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record 4. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Wound location, measurements and characteristics documented
The facility staff failed to document descriptions, measurements, and staging of two wounds after the initial admission documentation, until the wound care physician saw the resident approximately seven days after admission; and, failed to evidence that treatment was initiated until two days after admission.
Resident #205 was admitted to the facility on [DATE] and discharged on 9/22/22. A review of the admission MDS (Minimum Data Set) dated 8/24/22, revealed the resident was admitted with two stage-two pressure wounds.
Review of the clinical record failed to reveal any evidence of where the MDS staging came from as it was not documented anywhere. Also, the clinical record failed to reveal evidence that treatment was initiated upon admission and for the first two days of admission.
A review of the clinical record revealed the following orders and administration of those orders, in chronological order of the order date:
An order 8/18/22 for wound consult as-needed. The wound physician notes were reviewed. The wound physician saw the resident on 8/22/22, 8/31/22, 9/14/22, and 9/21/22.
An order 8/18/22 for right buttock - cleanse with normal saline, pat dry, cover with medihoney foam every day shift. A review of the TAR (Treatment Administration Record) for August 2022 revealed this order was discontinued on 8/20/22 and was administered as ordered.
An order 8/20/22 for bilateral buttocks - cleanse with normal saline, pat dry, cover with medihoney foam every day shift for wound. A review of the TAR for August 2022 revealed this order was discontinued on 8/24/22 and was administered as ordered.
An order 8/24/22 left buttock - cleanse with normal saline, pat dry, cover with medihoney and foam every day shift. A review of the TAR for August and September 2022 revealed this order was discontinued on 9/8/22 and was administered as ordered.
An order 8/24/22 right buttock - cleanse with normal saline, pat dry, cover with medihoney and foam every day shift for wound. A review of the TAR for August and September 2022 revealed this order was discontinued on 9/8/22 and was administered as ordered.
An order 9/8/22 barrier cream to bilateral buttocks every shift. A review of the TAR revealed this order was discontinued upon discharge and was completed as ordered except one time out of 42 opportunities it was not documented. There was no evidence whether it was done and not documented or was not done. There was no evidence that this resulted in any negative impact on the resident.
Further review of the clinical record revealed the following notes and assessments, in chronological order:
The admission nurse's note dated 8/17/22 documented the resident arrived at 8:15 PM and that there was a .right buttock open red area 1 cm open area on left buttock approximately 1 cm wide .
The nurse practitioner note dated 8/18/22, the initial assessment of this resident, did not address the wounds.
A skin assessment dated [DATE] at 4:02 PM documented Number of new skin conditions: 0. Comments: open area to buttocks
The nurse practitioner note dated 8/20/22 at 4:01 PM documented, .skin: .Bilateral buttock wounds wound care order updated
The nurse practitioner note dated 8/22/22 at 10:14 AM documented, .buttocks wounds assessed, dressing lifted .
The nurse practitioner note dated 8/24/22 at 12:23 PM documented, .seen in bed, wounds assessed with wound MD, b/l (bilateral) buttocks wounds healing well .
The wound physician note dated 8/24/22 documented, .Stage 3 pressure wound right buttock .Wound Size (L x W x D) 2.9 x 1.6 x 0.1 .Stage 3 pressure wound of the left buttock .Wound Size (L x W x D) 3 x 2.1 x 0.1 .
The wound physician note on 8/24/22 was the first with complete measurements, staging, and description of the wounds, which was approximately seven days after admission. There was no evidence of measurements other than the one centimeter documented on admission which was not a complete measurement, any description other than red and open area on admission, and any staging of these wounds prior to this note. In addition, there was no evidence that any wound treatment was initiated upon admission when the wound was initially identified, until approximately 16 hours after admission, and the first application of this treatment was not documented until 8/19/22, per the August 2022 TAR.
The wound physician note dated 8/31/22 documented, .Stage 3 pressure wound right buttock .Wound Size (L x W x D) 1.4 x 0.9 x 0.1 .Stage 3 pressure wound of the left buttock .Wound Size (L x W x D) 2.6 x 0.5 x not measureable .
The next wound physician note was dated 9/14/22. This note documented that as of 9/14/22, both wounds were resolved. There were no other wounds on this review note.
On 9/13/23 at 8:52 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that when a resident is admitted with wounds, the wounds should be assessed, cleaned and dressed. She stated that staff should obtain wound orders for it, implement the orders, and the next morning the unit manager and the doctor go in and do their assessment. She stated that wounds should be accurately documented as to what the resident has and where they are located, a detailed description of the wound and treatment should be initiated right away. She stated that when staff assess a wound, they are going to have to dress it, and that treatment orders should have been obtained immediately.
On 9/13/23 at 9:52 AM, an interview was conducted with ASM #4 (Administrative Staff Member), the nurse practitioner. She stated that the wounds were healed. She did not have any concerns regarding the wound treatment.
On 9/13/23 at 10:10 AM, an interview was conducted with ASM #5, the wound care physician. He did not recall the resident and was unable to speak to the pressure wounds prior to his initial evaluation of the wound, approximately one week after admission.
On 9/13/23 at 10:46 AM, an interview was conducted with RN #2 (Registered Nurse), the MDS nurse. She stated that when the resident was admitted , he came in with two open areas. She stated that she made her own observations of the resident's wounds in order to stage them for the MDS because there was no staging documented in the clinical record. She stated that she does not know what day she made the observation but that typically, she does her observations and interviews on or close to the ARD (Assessment Reference Date) of the MDS. The ARD for the admission MDS was 8/24/22, the same day as the wound care physician's first visit. She stated that her observations and interviews would not have been done the day of or in the day or two following admission; it would have been closer to the ARD date.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4, the unit manager. She stated that the initial skin check and then two more in the next 24 hours should be done-at admission and each following shifts for two more times. She stated that documentation should be as descriptive as possible. She stated that the nurse practitioner or physician should then go in and see the wounds to verify what stage they are. She stated that RN's are able to stage wounds but not everyone is comfortable. She stated that she tries to see all wounds in the first 24 hours. She stated that she would do a description and her own clinical opinion on what the stage is. She stated that there should have been treatment initiated and a note that wound care was provided and that orders should have been obtained on admission to get something started. She stated that there should be documentation on wound sizing, description, and staging. She stated that there should have been better documentation of the wound and wound care initiated and a note that wound care was provided even if there wasn't an order in place yet.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services in a sanitary manner for one of 37 residents in...
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Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services in a sanitary manner for one of 37 residents in the survey sample, Residents #21.
The findings include:
For Resident #21 (R21), the facility staff failed to store a CPAP (continuous positive airway pressure) (1) mask in a sanitary manner.
R21 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive sleep apnea (2).
On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/14/2021, R21 scored 15 out of 15 on the BIMS (brief interview for mental status), the resident was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R21 for CPAP while a resident.
On 09/11/23 at approximately 12:32 p.m., an observation of R21's room revealed a CPAP mask laying on the over-the-bed table uncovered.
On 09/11/23 at approximately 4:30 p.m., an observation of R21's room revealed a CPAP mask laying on the over-the-bed table uncovered.
On 09/12/23 at approximately 9:00 a.m., an observation of R21's room revealed a CPAP mask laying on the over-the-bed table uncovered.
The physician's order for R21 documented in part, CPAP to be on when laying down as tolerated set at prescribed settings. every shift for hypoxia. Start Date: 06/15/2021.
On 09/12/23 at approximately 9:01 a.m., an interview was conducted with R#38. When asked about the storage of the CPAP mask she stated that the facility have not provided a bag to store it in and that she is unable to reach the mask and relies of the staff to place the mask in a bag.
On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. After informed of the above observations she was asked how a resident's CPAP mask should be stored when it is not being used. ASM #2 stated that it should be covered to keep it clean.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm.
(2) Sleep apnea is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html.
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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence communication with the dialysis center for each dialysis vis...
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Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence communication with the dialysis center for each dialysis visit for one of two residents in the survey sample that received dialysis services; Resident #91.
The findings include:
For Resident #91, there were no dialysis communication sheets for 8/31/23, 9/2/23 and 9/9/23; and incomplete dialysis communication sheets for 8/29/23 and 9/5/23.
The facility policy, Hemodialysis was reviewed. This policy documented, Guests/residents receiving hemodialysis will be assessed pre and post treatment, and receive necessary interventions 4. The facility completes the appropriate section of the hemodialysis communication form prior to guest/resident receiving each dialysis session and again when the guest/resident returns from hemodialysis .
A review of the clinical record revealed an order dated 8/21/23 for dialysis on Monday, Wednesday, and Friday; and an order dated 8/30/23 changing the dialysis days to Tuesday, Thursday and Saturday.
A nurse's note dated 8/27/23 that documented, Guest notified writer that his dialysis has changed to Tue, Thur and Sat (Tuesday, Thursday, Saturday) starting on Tue 8/29/2023 This is in support of the above order changing the dialysis days.
The information was not included on the dialysis communication sheet from the dialysis center to the facility on 8/25/23. It is not documented if this change was initiated by the dialysis center on 8/25/23 or by the resident in the days following dialysis on 8/25/23.
A review of the dialysis communication log revealed the communication sheet dated 8/29/23 did not contain any communication from the dialysis center to the facility and did not contain the resident's name to validate that it was even for this resident.
The dialysis sheet dated 9/5/23 did not contain the resident's name to validate that it was applicable for this resident.
Further review revealed there was no communication sheets dated 8/31/23, 9/2/23 and 9/9/23.
On 9/12/23 at 4:10 PM, an interview was conducted with LPN #1 (Licensed Practical Nurse). She stated that there should be completed communication sheets for every visit so that each facility knows what is going on with the resident.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that dialysis communication sheets should be completed for each visit by the facility and the dialysis center.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure all bed rail requirements were met for one of 37 re...
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Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure all bed rail requirements were met for one of 37 residents in the survey sample, Resident #87.
The findings include:
For Resident #87 (R87), the facility staff failed to review the risks and benefits of bed rails with the resident and obtain informed consent.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.
A review of R87's clinical record revealed a physician's order dated 2/17/23 for a right assist bar (bed rail) to aide in turning and repositioning. A physical device evaluation dated 2/20/23 documented the use of an assist bar enabled increased bed mobility and enabled the resident to reposition self.
On 9/11/23 at 2:48 p.m., R87 was observed lying in bed with a right assist bar in the upright position.
On 9/12/23 at 1:49 p.m., an interview was conducted with R87. When asked, the resident stated that the facility staff had not explained the risks and benefits of the assist bar until about an hour before the interview when a staff member had the resident sign a form.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the nurses have to get special permission for residents to use assist bars and someone in the nursing department should educate residents about the use of assist bars and obtain informed consent.
On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Side Rail/Bed/Mattress Spacing and Mechanical Requirements documented, 2. If a side rail is implemented the facility must obtain informed consent from the resident or if applicable, the resident representative for the use of side rails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to ensure a resident's needs we...
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Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to ensure a resident's needs were met for one of 37 residents in the survey sample, Resident #24.
The findings include:
For Resident #24 (R24) the facility staff failed to provide incontinence care due to insufficient nursing staff.
R24 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and abnormalities of gait and mobility.
On 09/11/23 at 12:35 p.m., an observation revealed that R24, who resided on the west unit at the facility, activated the call bell for incontinence care.
On 09/11/23 at 12:45 p.m., an observation revealed CNA (certified nursing assistant) #2 entered R24's room, turned off the call and left the room with R24's lunch tray.
On 09/11/2023 at 1:00 p.m., an observation revealed LPN (licensed practical nurse) #4 entered R24's room and provided incontinence care.
The facility's as-worked schedule for 09/11/2023 documented eight certified nursing assistants were scheduled for the 7:00 a.m. to 3:00 p.m. shift, four on the west unit and four on the east unit.
On 09/11/23 at 12:57 p.m., an interview was conducted with R24. When asked about CNA #2 entering her room R24 stated that she told CNA #2 that she was wet and needed to be cleaned.
On 09/12/23 at approximately 1:06 p.m., an interview was conducted with CNA (certified nursing assistant) #2. When asked about her entering R24's room at approximately 12:45 p.m., the day before, she stated that she picked up R24's meal tray and that R24 asked if she would clean her up. CNA #2 stated that she told R24 that when she finished picking up the meal trays she would come back and provide incontinence care. When asked what time she finished picking up the meal trays, CNA #2 stated that it was after 1:00 p.m. but could not recall the exact time. When asked why R24 had to wait for incontinence care CNA #2 stated that the unit was short staffed and that there were three CNAs for 60 residents.
On 09/12/2023 at approximately 4:16 p.m., an interview was conducted with CNA #1, staffing coordinator. When asked to describe the minimal staffing requirements to provide adequate and consistent resident care CNA #1 stated that with the facility census there should be six CNAs on the west unit and six CNAs on the east unit during the 7:00 a.m. to 3:00 p.m. shift and two LPNs (licensed practical nurses) on each unit during the 7:00 a.m. to 3:00 p.m. shift. When asked about the staffing on Monday, 09/11/2023, she stated that there were four CNAs on each of the units, and explained that the facility has had CNAs drop to prn (as needed) status, some have been terminated and CNAs call out. When asked how she addresses the short staffing CNA #1 stated that she calls staff who are off trying to get them to come in to cover and that the facility does not use agency staff. When asked if not enough staff having effects the quality of resident care she stated yes.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a diet to me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a diet to meet a resident's needs for one of 37 residents in the survey sample, Resident #310.
The findings include:
For Resident #310 (R310), the resident was discharged from the hospital on 2/17/23 with a recommendation for a diabetic diet. The facility staff failed to obtain a physician's order for R310's diet until 2/20/23. R310 was served a regular diet until a physician's order for a consistent carbohydrate diet with no added salt was obtained on 2/20/23.
A hospital orthopedic surgery progress note dated 2/16/23 documented, Assessment/Plan: Diet: diabetic .
R310 was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of R310's physician's orders failed to reveal any dietary orders until 2/20/23. A dietary communication form dated 2/18/23 documented the resident's diet as regular.
A facility form titled, Guest/Resident, Family, Employee, and Visitor Assistance Form dated 2/20/23 documented, What is your concern about? Diet. I am diabetic .When did the problem or incident occur? Since 2/17/23. FACILITY RESPONSE: Dietary received a new admission slip for guest on 2/18/23 which is a Saturday, diet slip stated guest was a regular diet. ACTION TO BE TAKEN: Dietary director will go see guest for food preferences . A registered dietician nutritional evaluation dated 2/20/23 documented, Utilizes insulin pump for DM (diabetes mellitus) management, follows a strict CHO (carbohydrate) counting diet for DM . Further review of R310's clinical record revealed a physician's order dated 2/20/23 for a consistent carbohydrate diet with no added salt.
On 9/12/23 at 4:59 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that when a resident is admitted to the facility, the nurses usually obtain the resident's diet order from the hospital, are told the diet order during the phone report from the hospital, or the nurses will look through the hospital discharge paperwork which will usually indicate the diet the resident should be provided. RN #3 stated the nurses are responsible for entering the diet order into the computer system and providing a diet communication form to the kitchen on the day of admission.
On 9/13/23 at 8:19 a.m., an interview was conducted with OSM (other staff member) #4 (the registered dietician). OSM #4 stated that on the day of admission, the nurses are supposed to enter a diet order into the computer system, and this is usually the diet that the hospital staff has placed the resident on. OSM #4 stated that within a week, she evaluates the resident and changes the diet order if needed. OSM #4 stated she evaluated R310 on 2/20/23 and a consistent carbohydrate diet with no added salt was prescribed on that date. OSM #4 stated this was equivalent to a diabetic diet.
On 9/13/23 at 9:01 a.m., an interview was conducted with OSM (other staff member) #5 (the former dietary manager). OSM #5 stated residents' prescribed diets are communicated from the nursing staff to the dietary staff via dietary communication forms. OSM #5 stated the diet that is documented on the communication form and provided to the kitchen is the diet that is entered into the dietary meal tracker system and the diet that is provided.
On 9/13/23 at 3:07 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Diet Orders documented, 1. The Nurse will obtain a Physician order for the type of diet needed upon admission/readmission and when a diet change is needed. 2. The Nurse or Designee will provide a written Diet Order and Communication form of the change to the Dietary department.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens.
The findings include:
Th...
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Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens.
The findings include:
The facility staff failed to close a box containing a bag of breaded fish filets, exposing them to the environment, in one of one walk-in freezers.
On 09/11/2023 at approximately 11:45 a.m., an observation of the facility's walk-in freezer was conducted with OSM (other staff member) #1, dietary manager. Observation of the middle shelf on the right side inside the freezer revealed a ten-pound box of breaded fish filets. Observation of the box revealed that the box and the inside packaging was open to the environment. When asked how much was left in the box OSM #1 stated it about half remaining. OSM #1 further stated that the box should have been closed and immediately removed it from the freezer.
The facility's policy Food Purchasing and Storage documented in part, All frozen food will be dated, labeled, and wrapped or sealed. Moisture-proof, tightfitting materials will be used to prevent freezer burn.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
4.a. For Resident #87 (R87), the facility staff failed to implement the resident's comprehensive care plan for pain management.
On the most recent MDS (minimum data set), a quarterly assessment with a...
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4.a. For Resident #87 (R87), the facility staff failed to implement the resident's comprehensive care plan for pain management.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.
R87's comprehensive care plan dated 11/12/22 documented, (R87) is at risk for pain r/t (related to) h/o (history of) multiple falls, chronic T12 (thoracic) compression fracture, fibromyalgia, degenerative arthritis, hx (history) ankle pain, back pain, right should contusion, bilateral knees .
Interventions: Offer Non-Pharmacological Interventions:
1)Massage
2)Meditation/Relaxation
3)Positioning
4)Ice/cold pack
5)Diversional Activity
6)Guided Imagery
7) Rest
8)Social Interaction .
A review of R87's clinical record revealed a physician's order dated 1/20/23 for ibuprofen 200 mg (milligrams)- one tablet by mouth every six hours as needed for pain. A review of R87's September 2023 MAR (medication administration record) revealed the resident was administered as needed ibuprofen on 9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/6/23, 9/7/23 and 9/8/23. Further review of R87's clinical record (including the September 2023 MAR and September 2023 nurses' notes) failed to reveal non-pharmacological interventions were offered or attempted on all dates.
On 9/12/23 at 1:49 p.m., an interview was conducted with R87, who stated the nurses do not offer non-pharmacological interventions for pain management.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated care plans are individualized because everybody has different needs. LPN #3 stated the care plans tell you about what is needed to be done and if anyone has questions, they can look at the care plans. LPN #3 stated that prior to the administration of an as needed pain medication, nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted.
On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
4.b. For Resident #87 (R87), the facility staff failed to implement the resident's comprehensive care plan for thyroid replacement therapy.
R87's comprehensive care plan dated 11/12/22 documented, (R87) is at risk for complications of hypothyroidism such as: intolerance to cold, decreased appetite, weight gain, dry skin, mood changes, constipation, fatigue & bradycardia (low heart rate) .Administer thyroid replacement therapy as ordered .
A review of R87's clinical record revealed a physician's order dated 9/6/23 for levothyroxine sodium (1) 75 mcg (micrograms)- one tablet by mouth in the morning for hypothyroidism. A review of R87's September 2023 MAR (medication administration record) revealed the same physician's order for levothyroxine sodium. On 9/10/23 and 9/11/23, the MAR documented the code, 5=Hold./See Nurse Notes Nurses' notes dated 9/10/23 and 9/11/23 documented the medication was not available in the medication cart. Further review of nurses' notes and the September 2023 MAR failed to reveal documentation that levothyroxine sodium was administered to R87 on 9/10/23 and 9/11/23.
A review of the facility backup medication supply list revealed levothyroxine sodium 75 mcg tablets were available in the supply.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated care plans are individualized because everybody has different needs. LPN #3 stated the care plans tell you about what is needed to be done and if anyone has questions, they can look at the care plans. LPN #3 stated nurses should re-order medications from the pharmacy when there are five or six pills left. LPN #3 stated if a medication is not available for administration, the medication should be pulled from the backup medication supply, and if the medication is not available in the supply, then the nurses should call the pharmacy and ask for the medication to be sent STAT (immediately).
On 9/13/23 at 3:07 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
Reference:
(1) Levothyroxine is used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682461.html.
5. For Resident #7 (R7) the facility staff failed to implement the comprehensive care plan for the use of non-pharmacological interventions prior to the administration of a prn (as needed) pain medication, Tramadol (1).
R7 was admitted with diagnosis that included but not limited to osteoarthritis (2) of the knee.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R7 was cognitively intact for making daily decisions. Section J Pain Management coded R7 as having frequent pain at a pain level of six out of ten, with ten being the worse pain.
The physician order for R7 documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligrams). Give 1 (one) tablet by mouth every 8 (eight) hours as needed for Pain level 6-10. Order Date: 10/25/2022.
The eMAR (electronic medication administration record) for R7 dated august 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 67 doses of Tramadol 50mgs between 08/01/2023 and 08/31/2023 with no evidence of non-pharmacological interventions being attempted and documentation of the location of R7's pain and the type of pain.
The eMAR (electronic medication administration record) for R7 dated September 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 20 doses of Tramadol 50mgs between 09/01/2023 and 09/11/2023 with no evidence of non-pharmacological interventions being attempted prior to the administration of Tramadol for R7.
The nursing progress notes for R7 dated 08/01/2023 through 09/11/2023 failed to evidence documentation of non-pharmacological interventions being attempted prior to the administration of Tramadol for R7.
R7's comprehensive care plan dated 02/22/2022 documented in part, Need. (R7) actual pain episodes r/t (related to) severe L (left) knee OA (osteoarthritis) with debility, Chronic pain d/t (due to) RA (rheumatoid arthritis), lumbar radiculopathy, h/o (history of) migraines, DM (diabetes mellitus) with neuropathy. Date Initiated: 02/22/2022. Under Interventions it documented in part, Offer Non-Pharmacological Interventions. 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional activity. 6) Guided Imagery. 7) Rest. 8) Social interaction. 9)Other. Date Initiated: 02/22/2022.
On 09/12/23 at approximately 9:21 a.m., an interview was conducted with R7. When asked if the facility staff attempt non-pharmacological intervention prior to administrating Tramadol, R7 stated no.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. She stated in regard to non-pharmacological interventions, LPN #3 stated nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Tramadol is used to relieve moderate to moderately severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html.
(2) The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html.
Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 37 residents in the survey sample; Residents #100, #88, #91, #87, and #7.
The findings include:
The facility policy, Care Planning was reviewed. This policy documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs .
1. For Resident #100, the facility staff failed to implement the comprehensive care plan for the use of an anticoagulant medication.
A review of the clinical record revealed an order dated 8/25/23 for Eliquis (1) 5 mg (milligrams) twice daily for seven days; and an order dated 9/2/23 for Eliquis 5 mg once daily.
A review of the comprehensive care plan revealed one dated 8/25/23 for (Resident #100) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/25/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/25/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds.
Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects.
On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. When asked if the care plan documented to monitor, how do you evidence that you followed it, she stated, Your documentation. She stated that if there is no documentation evidence then the care plan is not being followed.
On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. She stated that if there is no evidence of monitoring, then the care plan is not being followed.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. She stated that the care plan is not being followed if it is not documented.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
References:
(1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed.
Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html
2. For Resident #88, the facility staff failed to implement the comprehensive care plan for the use of an anticoagulant medication.
A review of the clinical record revealed an order dated 8/5/23 for Apixaban (1) (same as Eliquis) 5 mg (milligrams) twice daily for atrial fibrillation.
A review of the comprehensive care plan revealed one dated 3/20/23 for (Resident #88) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 3/20/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 3/20/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds.
Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects.
On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. When asked if the care plan documented to monitor, how do you evidence that you followed it, she stated, Your documentation. She stated that if there is no documentation evidence then the care plan is not being followed.
On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. She stated that if there is no evidence of monitoring, then the care plan is not being followed.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. She stated that the care plan is not being followed if it is not documented.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
References:
(1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed.
Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html
3. For Resident #91, the facility staff failed to implement the comprehensive care plan for the use of an anticoagulant medication.
A review of the clinical record revealed a physician's order dated 9/11/23 for Coumadin (1) 5 mg (milligrams) daily, on Monday, Tuesday, Wednesday, Thursday, and Friday; and an order dated 9/11/23 for Coumadin 9.5 mg Saturday and Sunday, for atrial fibrillation.
A review of the comprehensive care plan revealed one dated 8/21/23 for (Resident #91) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/21/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/21/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds.
Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects.
On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. When asked if the care plan documented to monitor, how do you evidence that you followed it, she stated, Your documentation. She stated that if there is no documentation evidence then the care plan is not being followed.
On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. She stated that if there is no evidence of monitoring, then the care plan is not being followed.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. She stated that the care plan is not being followed if it is not documented.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
References:
(1) Coumadin - Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a heart attack. Warfarin is also used to treat or prevent venous thrombosis (swelling and blood clot in a vein) and pulmonary embolism (a blood clot in the lung).
Information obtained from https://medlineplus.gov/druginfo/meds/a682277.html
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in ...
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Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in the survey sample, Residents #87 and #7.
The findings include:
1. For Resident #87 (R87), the facility staff failed to initiate a complete pain assessment and failed to attempt non-pharmacological interventions when the as needed pain medication ibuprofen was administered on multiple dates in September 2023.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.
A review of R87's clinical record revealed a physician's order dated 1/20/23 for ibuprofen 200 mg (milligrams)- one tablet by mouth every six hours as needed for pain. A review of R87's September 2023 MAR (medication administration record) revealed the resident was administered as needed ibuprofen on 9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/6/23, 9/7/23 and 9/8/23. Further review of R87's clinical record (including the September 2023 MAR and September 2023 nurses' notes) failed to reveal a completer pain assessment (including location, quality and duration) was completed on all dates and failed to reveal non-pharmacological interventions were offered or attempted on all dates.
On 9/12/23 at 1:49 p.m., an interview was conducted with R87. R87 stated that sometimes the nurses ask the resident's pain level prior to administering ibuprofen but the nurses do not ask the location and description of the pain. R87 further stated the nurses do not offer non-pharmacological interventions.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that prior to administering an as needed pain medication, the nurses should ask the resident where the pain is, ask the resident if the pain is throbbing or sharp, ask the resident to rate the pain, ask the resident if the pain is new, observe for non-verbal indicators of pain, and document the assessment. LPN #3 stated a complete pain assessment is important because the pain may be something that requires more than just a pain pill. LPN #3 stated the resident may need to be seen by a doctor or transferred out of the facility. In regard to non-pharmacological interventions, LPN #3 stated nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted.
On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Pain Management documented, 1. Upon admission/re-admission, quarterly, with a significant change in condition and PRN (as needed) residents will be evaluated for pain by the licensed nurse. 2. Additionally, residents will be monitored for the presence of pain and evaluated when there is a change in condition and whenever new pain or an exacerbation of pain is suspected. 3.Observe resident for indicators of pain (refer to table 3), indicators include:
-Moaning, crying, and other vocalizations
-Wincing or frowning and other facial expressions
-Body posture such as guarding or protecting an area of the body, or lying very still
-Decrease in usual activities .
5. Ask the resident and observe to determine the frequency of pain:
-No pain
-Pain less than daily
-Pain daily .
7. Ask the resident and observe to determine the location of pain .
9. Each resident identified with pain will have a Pain Management Care Plan. The care plan will have: Individualized interventions related to that resident's individual control of pain management should include both pharmacological, non-pharmacological, and include Complementary and Alternative Medicine (CAM) pain management interventions .
2. For R7 the facility staff failed to identify the location of the pain, the type of pain and attempts of non-pharmacological interventions prior to the administration of a prn (as needed) pain medication, Tramadol (1).
R7 was admitted with diagnosis that included but not limited to osteoarthritis (2) of the knee.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R7 was cognitively intact for making daily decisions. Section J Pain Management coded R7 as having frequent pain at a pain level of six out of ten, with ten being the worse pain.
R7's comprehensive care plan dated 02/22/2022 documented in part, Need. (R7) actual pain episodes r/t (related to) severe L (left) knee OA (osteoarthritis) with debility, Chronic pain d/t (due to) RA (rheumatoid arthritis), lumbar radiculopathy, h/o (history of) migraines, DM (diabetes mellitus) with neuropathy. Date Initiated: 02/22/2022. Under Interventions it documented in part, Offer Non-Pharmacological Interventions. 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional activity. 6) Guided Imagery. 7) Rest. 8) Social interaction. 9)Other. Date Initiated: 02/22/2022.
The physician order for R7 documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligrams). Give 1 (one) tablet by mouth every 8 (eight) hours as needed for Pain level 6-10. Order Date: 10/25/2022.
The eMAR (electronic medication administration record) for R7 dated august 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 67 doses of Tramadol 50 mgs between 08/01/2023 and 08/31/2023, with no evidence of non-pharmacological interventions attempted and no documentation of the location and type of R7's pain.
The eMAR (electronic medication administration record) for R7 dated September 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 20 doses of Tramadol 50 mgs between 09/01/2023 and 09/11/2023 with no evidence of non-pharmacological interventions attempted and no documentation of the location and type of R7's pain.
The nursing progress notes for R7 dated 08/01/2023 through 09/11/2023 failed to evidence documentation of non-pharmacological interventions prior to the administration of Tramadol and the location and type of R7's pain.
On 09/12/23 at approximately 9:21 a.m., an interview was conducted with R7. When asked if the facility staff attempt non-pharmacological intervention, ask for the location of pain or type of pain prior to administrating Tramadol, R7 stated no.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that prior to administering an as needed pain medication, the nurses should ask the resident where the pain is, ask the resident if the pain is throbbing or sharp, ask the resident to rate the pain, ask the resident if the pain is new, observe for non-verbal indicators of pain, and document the assessment. LPN #3 stated a complete pain assessment is important because the pain may be something that requires more than just a pain pill. LPN #3 stated the resident may need to be seen by a doctor or transferred out of the facility. In regard to non-pharmacological interventions, LPN #3 stated nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Tramadol is used to relieve moderate to moderately severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html.
(2) The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips, or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 37 residents in the survey sample, Resident #310.
The f...
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Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 37 residents in the survey sample, Resident #310.
The findings include:
For Resident #310 (R310), the facility staff failed to ensure multiple medications were available for administration on multiple dates in February 2023.
A review of R310'S clinical record revealed a physician's order dated 2/17/23 for alpha-lipoic acid (1) 300 mg (milligrams)- one capsule by mouth one time a day for supplement. A review of R310's February 2023 MAR (medication administration record) revealed the same physician's order for alpha-lipoic acid. On 2/18/23, 2/19/23, 2/20/23, 2/22/23, 2/23/23 and 2/24/23, the MAR documented the code, 5=Hold/See Nurse Notes. A nurse's note dated 2/18/23 documented the staff was waiting for delivery of the medication. A nurse's note dated 2/19/23 documented the medication was not available. A nurse's note dated 2/20/23 documented the medication was held until available. A nurse's note dated 2/22/23 documented the staff was waiting for delivery of the medication. A nurse's note dated 2/23/23 documented the pharmacy stated insurance would not pay for the medication and the facility had to pay. A nurse's note dated 2/24/23 documented the medication was not available.
Further review of R310's clinical record revealed a physician's dated 2/17/23 for Flonase (2) nasal suspension 50 mcg (micrograms)- one spray in both nostrils two times a day for allergy. A review of R310's February 2023 MAR revealed the same physician's order for Flonase. For the morning doses on 2/18/23 and 2/22/23, the MAR documented the code, 5=Hold/See Nurse Notes. A nurse's note dated 2/18/23 documented the medication was in route from the pharmacy. A nurse's note dated 2/22/23 documented the medication was in route from the pharmacy and would be given at the next administration time.
Further review of R310's clinical record revealed a physician's order dated 2/20/23 for Mirabegron (3) 25 mg- one tablet by mouth two times a day for bladder spasms. A review of R310's February 2023 MAR revealed the same physician's order for Mirabegron. For the morning doses on 2/21/23 and 2/22/23, the MAR documented the code, 5=Hold/See Nurse Notes. A nurse's note dated 2/22/23 documented the staff was waiting for delivery of the medication from the pharmacy.
A review of the facility backup medication supply list revealed alpha-lipoic acid, Flonase, and Mirabegron were not available in the supply.
On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated if a medication is newly ordered, the medication should be pulled from the backup medication supply, and if the medication is not available in the supply, then the nurses should call the pharmacy and ask for the medication to be sent STAT (immediately).
On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Medication Administration documented, Medications are administered in accordance with written orders of the attending physician. The facility pharmacy policy titled, Providing Pharmacy Products and Services documented, Pharmacy will provide Facility with the Facility-specific information sheet set forth in the Facility-Specific Information Sheet which details how Facility staff can contact Pharmacy twenty four (24) hours a day, seven (7) day a week.
References:
(1) People most commonly use alpha-lipoic acid for nerve pain in people with diabetes. This information was obtained from the website: https://medlineplus.gov/druginfo/natural/767.html
(2) Flonase is used to relieve allergies. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695002.html
(3) Mirabegron is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a612038.html
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 F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
4. For R7, the facility staff failed to administer a prn (as needed) the pain medication Tramadol (1) within the physician ordered pain level parameters.
R7 was admitted with diagnosis that included ...
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4. For R7, the facility staff failed to administer a prn (as needed) the pain medication Tramadol (1) within the physician ordered pain level parameters.
R7 was admitted with diagnosis that included but not limited to osteoarthritis of the knee (2).
The physician order for R7 documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligrams). Give 1 (one) tablet by mouth every 8 (eight) hours as needed for Pain level 6-10. Order Date: 10/25/2022.
The eMAR (electronic medication administration record) for R7 dated August 2023 documented the physician order as stated above. Further review of the eMAR revealed that (R7) received 50 mgs of Tramadol for a pain level of five on 08/01/2023, 08/03/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/15/2023, 08/23/2023, 08/27/2023 and on 08/31/2023.
The eMAR for R7 dated September 2023 documented the physician order as stated above. Further review of the eMAR revealed that (R7) received 50 mg of Tramadol for a pain level of five on 09/03/2023, 09/06/2023 and on 09/08/2023.
On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. After reviewing the physician order, and the August 2023 and September 2023 eMARS she was asked if the pain medication for R7 was administered according to the physician's orders for the dates listed above. ASM #2 stated no, and that the medication was administered outside of the physician's ordered parameters.
On 09/12/2023 at approximately 5:07 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Tramadol is used to relieve moderate to moderately severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html.
(2) The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips, or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html.
Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure residents were free from unnecessary medications for four of 37 residents in the survey sample; Residents #100, #88, #91, and #7.
The findings include:
The facility policy, Anticoagulant Therapy was reviewed. This policy documented, Anticoagulant therapy is utilized as a prophylaxis and treatment of venous thrombosis, pulmonary embolism, thrombotic disorders, Atrial-Fibrillation with embolism and prophylaxis of systemic embolism after Myocardium Infarction. They inhibit the development of a thrombus 5. Throughout anticoagulant therapy monitor the guest/resident for signs and symptoms of bleeding. If signs and symptoms of bleeding are noted, hold anticoagulant medication and notify physician immediately.
1. For Resident #100, the facility staff failed to monitor for the use of an anticoagulant medication.
A review of the clinical record revealed an order dated 8/25/23 for Eliquis (1) 5 mg (milligrams) twice daily for seven days; and an order dated 9/2/23 for Eliquis 5 mg once daily.
A review of the comprehensive care plan revealed one dated 8/25/23 for (Resident #100) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/25/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/25/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds.
Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects.
On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself.
On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
Reference:
(1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed.
Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html
2. For Resident #88, the facility staff failed to monitor for the use of an anticoagulant medication.
A review of the clinical record revealed an order dated 8/5/23 for Apixaban (1) (same as Eliquis) 5 mg (milligrams) twice daily for atrial fibrillation.
A review of the comprehensive care plan revealed one dated 3/20/23 for (Resident #88) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 3/20/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 3/20/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds.
Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects.
On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself.
On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
Reference:
(1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed.
Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html
3. For Resident #91, the facility staff failed to monitor for the use of an anticoagulant medication.
A review of the clinical record revealed a physician's order dated 9/11/23 for Coumadin (1) 5 mg (milligrams) daily, on Monday, Tuesday, Wednesday, Thursday, and Friday; and an order dated 9/11/23 for Coumadin 9.5 mg Saturday and Sunday, for atrial fibrillation.
A review of the comprehensive care plan revealed one dated 8/21/23 for (Resident #91) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/21/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/21/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds.
Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects.
On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself.
On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident.
On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done.
On 9/13/23 at 11:23 AM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided.
Reference:
(1) Coumadin - Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a heart attack. Warfarin is also used to treat or prevent venous thrombosis (swelling and blood clot in a vein) and pulmonary embolism (a blood clot in the lung).
Information obtained from https://medlineplus.gov/druginfo/meds/a682277.html
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift on two of ...
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Based on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift on two of three survey dates.
The findings include:
The facility staff failed to post nurse staffing information on 9/11/2023 and 9/12/2023 prior to the beginning of the nursing staff work shift.
On 9/11/2023 at 2:19 p.m., an observation was made of the facility's lobby which revealed the staff posting dated 9/7/2023.
On 9/11/2023 at 4:30 p.m., an observation was made of the facility's lobby which revealed the staff posting dated 9/7/2023.
On 9/12/2023 at 8:19 p.m., an observation was made of the facility's lobby which revealed the staff posting dated 9/7/2023.
On 9/12/2023 at 10:00 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the scheduling coordinator posted the staffing each day when they arrived. She stated that the scheduling coordinator had been working on the floor as an aide so she and the administrator had been assisting to post the staffing. She stated that they filled out a daily staffing sheet from the master schedule and posted it at the front desk in the lobby each morning. She stated that the daily staff posting should be posted each day. ASM #2 was made aware of the observations of the staff posting dated 9/7/2023 observed on 9/11/2023 and 9/12/2023 and stated that she was aware.
The facility policy, Required Regulatory Postings revised 4/19/2022 documented in part, .The facility posts the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for guest/resident care for each shift. The information will be displayed in a prominent location that is clearly visible and accessible by guests/residents, family and staff . Posting Requirements
i. The facility will post the data specified above on a daily basis at the beginning of each shift .
On 9/12/2023 at approximately 5:10 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator, were made aware of the concern.
No further information was presented prior to exit.
Mar 2022
17 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to administer the correct physician prescribed dose of the Pfizer COVID-19 vaccine to Resident #317...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to administer the correct physician prescribed dose of the Pfizer COVID-19 vaccine to Resident #317 (R317).
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/20/21, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions.
A review of R317's clinical record revealed a physician's order dated 12/16/21 for 0.3 ml (milliliters) of the Pfizer COVID-19 vaccine. A medication error report dated 12/16/21 documented R317 was administered 1.8 ml of the Pfizer vaccine. The report further documented the physician was notified, ordered intravenous normal saline at 50 ml per hour for one hour and R317 had no adverse outcome.
R 317's comprehensive care plan revised on 12/17/21 documented, [R317] is at risk for adverse reaction r/t (related to) unintentional over dosage of medication. IV (Intravenous) and run NS (normal saline) at 50ml/hr x 1 bag .
On 3/24/22 at 8:03 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who administered the Pfizer vaccine to R317). LPN #3 stated on 12/16/21, he assisted the assistant director of nursing with administering the Pfizer vaccine to residents. LPN #3 stated he was unclear on the instructions for diluting the medication and he administered the incorrect dose to R317. LPN #3 stated he was given instructions for administering the vaccine but he wasn't aware the medication had to be diluted and this was the first time he had drawn up the medication.
On 3/24/22 at 8:21 a.m., an interview was conducted with RN (registered nurse) #1 (the assistant director of nursing). RN #1 stated 12/16/21 was the first day she was charge at the facility and the director of nursing was not present. RN #1 stated on that day, she was completing multiple tasks and LPN #3 offered to assist with the Pfizer vaccines. RN #1 stated that at the time, she was not aware that the director of nursing usually drew up the vaccines and LPN #3 only administered them. LPN #3 stated she thought LPN #3 knew how to draw up the medication but she should have went with him and observed.
On 3/24/22 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding following physician's orders for medication administration. RN #2 stated nurses should read the MAR (medication administration record), find the medication, read the MAR again, read the medication and double check the medication against the MAR. RN #2 stated nurses should follow seven rights of medication administration that include the right individual, medication, dose, time, route, documentation and response. RN #2 stated she obtained this information several years ago from the national institute of health website.
On 3/24/22 at 9:20 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #3 (the regional director of operations) were made aware of the above concern.
The manufacturer's instructions for the Pfizer vaccine administered to R317 documented, Each vial must be thawed and diluted prior to administration. Dilute the vial contents using 1.8 mL of sterile 0.9% Sodium Chloride Injection .
No further information was presented prior to exit.
Based on resident interview, clinical record review, facility document review, staff interview and in the course of the medication administration observation, the facility staff failed to follow the physician's orders for 4 of 51 residents in the survey sample, Residents #16, #317, and #217; to include one of five residents in medication administration observation, Resident #9.
The findings include:
1. On 11/02/2021 at 10:00 p.m. and on 11/03/2021 at 6:00 a.m., the facility staff failed to follow the physician's order for Methadone, resulting in an overdose. Resident # 16 (R16) was administered 5ml (five milliliter) of methadone (1), ten times the physician-ordered dose, resulting in (R16's) oxygen saturation dropping to 77%, requiring an administration of Narcan (2) and being taken to the hospital for further interventions and monitoring. The overdose resulted in harm for Resident #16.
(R16) was admitted to the facility with diagnoses that included but were not limited to: lung cancer, respiratory failure and a blood clot in the lungs.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/22/2021, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0400 coded (R16) as frequently experiencing pain at a level of five out of 10 during the look back period.
On 03/22/22 at approximately 1:11 p.m., (R16) stated that approximately four months ago they were given an overdose of methadone and were sent to the hospital.
The physician's orders for (R16) documented in part, Methadone HCl (hydrochloride) Intensol Concentrate 10 MG(milligrams)/ML Give 0.5 ml orally every 8 (eight) hours for pain. Order Date: 11/02/2021 .Narcan Liquid 4 MG/0.1ML (milliliter) (Naloxone HCl) 0.1 ml in nostril STAT (immediately) for Sedation -Start Date11/03/2021.
The comprehensive care plan for (R16) dated 06/15/2021 documented in part, (R16) has pain r/t (related to): muscle weakness, Lung Cancer, Chronic Thromboembolic Pulmonary Hypertension ., Date Initiated: 06/15/2021 .Observe for side effects of pain medication. Date Initiated: 06/15/2021.
The facility's nurse's note dated 11/03/2021 documented, 7:25 a.m., Text: Med (medication) error noted during narcotic count at 7:15am. VS (vital signs) at that time 97.2 (temperature) -57 (pulse)-16 (respiration) -116/77 (blood pressure) O2 sat (oxygen saturation) 88-89% on 5L/min (five liters per minute) O2 via (by) NC (nasal cannula). Resident alert and responsive. UM (unit manager) notified of error and residents status. Hospice and MD (medical doctor) notified. New order for Narcan if O2 sat goes below 80%. CNA in room with resident. VS at 7:30 am 96.9-61-17-128/80 O2 sat 74%. Narcan given per order at 8:20am (a.m.). O2 sat increased to 87%. VS at 7:45am 97.1-60-18-130/86. MD in and stated to send resident to ER (emergency room) and increase O2 to 15L (liters) on non-rebreather mask. 911 called for transport. Resident becoming anxious- c/o (complaint of) being cold and shaky. VS at 8am 96.8-59-18-126/86 O2 sat 84%.Resident becoming restless. VS at 8:30am 97.1-71-18-127/88 O2 sat 91%. 911 in to transport at 8:50am. Family notified of residents condition and need to transport to hospital. Author: [Name of LPN (licensed practical nurse)] #2. Further review of the nurse's note revealed a handwritten noted that documented, Nurse during count stated I must have given 5ml instead of .5ml (0.5ml), and signed by LPN # 2.
The nurse's note dated 11/03/2021 at 8:36 a.m. documented, VS 97.2-57-16-116/77 O2 sat 88-89% on 5L/min via NC. O2 mask applied. O2 sat 93% but dropped to 77%. Narcaine [sic] given at 8:20am per MD order. O2 sat 91% but dropped to 77%. MD in and stated to send to ER (emergency room). Hospice notified. VS taken every 15 min. Resident alert and talking but slow. Voices no complaints at this time.
The facility form Analysis of Medication Event for (R16) dated 11/03/2021 documented in part, Date of Event: 11-2-21, 11-3-21. Time of Event: 2200 (10:00 p.m.) 6:00 a.m. Medication Given: Methadone. Dosage Given: 5mL. Route: po (by mouth). Cause of Event: How did the event occur?: Nurse gave wrong dosage X2 (times two) 2200 & (and) 6:00 am. What is the actual effect of the event on the guest? Decrease O2 Sat rate. How was event discovered? During am count by off going nurse and on coming nurse. Name(s) and title(s) of employee(s) involved: [Name of Registered Nurse (RN) #3].
The facility's Controlled Medication Utilization Record for (R16) documented in part, Methadone Intensol Concentrate 10 MG/1 (one)ML oral CONC (concentrate) 0.5 ml sublingually (under the tongue) three times daily for pain. Date: 11/2/21. Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL. Under Date: 11/3/21 it documented, Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL.
The Emergency Provider Report for (R16) from [Name of Hospital] dated 11/03/2021 documented in part, Free Text HPI (history of present illness) Notes. Patient with history significant for end-stage lung cancer, COPD, asthma, CAD, HTN, presents to the emergency department for reports of accidental overdose on methadone. Patient is on hospice in resides at [Name of Nursing Home], at which a hospice nurse visit him, helps distances [sic] pain medication. Reportedly patient is on known concentration of methadone, however was supposed to receive 0.5mL this morning, rather he received 5mL accidentally per staff. He then became minimally responsive. EMS (emergency medical services) was called, Narcan was administered EN (unknown abbreviation) route was immediately brought the patient around. Patient upon arrival reports being diffuse widespread pain, feeling as though he is going to vomit, having diarrhea. Patient denies feeling drowsy or having difficulty breathing currently. No chest pain. No recent fevers. No other medical complaints at this time.
The Discharge Summary for (R16) from [Name of Hospital] dated 11/04/2021 documented in part, Hospital Course. [AGE] year old with hx (history) of lung cancer ch (chronic history) resp (respiratory) failure on home O2 5lpm (liters per minute) was under Hospice care at SNF (skilled nursing facility) and was given accidental higher dose of methadone 5ml of intensol instead of 0.5ml and was noted to have AMS (altered mental status) and increase O2 needs, narcan given and pt (patient) was referred to ER, poison control was called by ER provider and was advised to be admitted for observation. HOV [Name of Hospice]) was called and pt will be admitted overnight as GIP (general inpatient) for monitoring. At time of my eval (evaluation) is awake and alert complain gof [sic] pain all over, I was able to switch pt to 5lpm O2 via NC. Pt was placed on monitoring and did well and will proceed with dc (discharge) back to SNF with HOV. Staff at SNF to exercise caution with use of narcotics.
On 03/23/2022 at approximately 12:10 p.m. an interview was conducted with LPN # 1 and LPN # 2, unit manager. When asked how the medication error was discovered LPN # 2 stated that when they were doing the medication count on 11/03/2021 for the 7:00 a.m. to 3:00 p.m. shift with RN #3, there was a discrepancy with the methadone. There was more was missing than should have been. LPN # 2 stated that RN #3 realized that [Name of R16] received too much methadone. When asked how much methadone had been administered to R16, LPN # 2 stated that they had received 5 milliliters instead of 0.5 milliliters. LPN # 2 stated that they checked [Name of R16's] vital signs, went back to the nurse's station and informed LPN # 1. LPN # 1 stated they informed LPN # 2 to call and notify hospice due to the fact that (R16) was under hospice care, then they assigned a CNA (certified nursing assistant) in (R16's) room to monitor their oxygen saturation. LPN #1 further stated that they notified the physician and they gave an order and to monitor the oxygen saturation and for narcan if the oxygen saturation dropped below 80%. When asked if the narcan was used LPN #1 stated that (R16's) oxygen saturation dropped to 77% and that LPN # 2 administered the narcan. LPN # 1 further stated that the physician was in the facility at that time, checked (R16's) vital signs and gave an order to have (R16) sent to the hospital by 911 and that by the time the EMTs (emergency medical technicians) arrived (R16's) oxygen saturation was up to 84%. When asked to interview RN #3, LPN # 1 stated that [Name of RN # 3] returned the next day, was supervised during their medication administration, and has never return to the facility. When asked how a nurse ensures the physician's orders are followed for medication administration, LPN # 1 stated that if it is a narcotic they should triple check the narcotic book, with the physician's orders, with the medication and follow the seven rights of medication administration that include the right route, medication, dose, patient, time, documentation and response.
On 03/23/2022 at 12:45 p.m., ASM (administrative staff member) # 1, administrator and ASM # 2, director of nursing, were informed of the above findings.
On 03/23/2022 at approximately 9:46 a.m., an interview was conducted with ASM #4, nurse practitioner. When asked about the use of methadone, ASM #4 stated that it is used for pain. When asked what the negative outcome would be if a resident was given an overdose of methadone, ASM #4 stated they would become too sedated, decrease their respiration and would have low oxygen saturation. When asked about the course of action that would be taken if an overdose occurred, ASM #4 stated that the resident would be monitored. When informed of the above resident and circumstances, ASM #4 stated that it was not their resident and that the actions taken sounded reasonable.
On 03/23/2022 at approximately 2:35 p.m., a telephone interview was conducted with ASM #5, (R16's) physician. ASM #5 recalled the circumstances of (R16's) overdose of methadone and stated that they received a call from the nurse, gave an order to monitor the oxygen saturation and for Narcan if the saturation dropped. ASM # 5 stated they were in the facility when the overdose was discovered, saw the oxygen saturation was declining, and sent the resident out to the hospital.
On 3/24/22 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding following physician's orders for medication administration. RN #2 stated nurses should read the MAR (medication administration record), find the medication, read the MAR again, read the medication and double check the medication against the MAR. RN #2 stated nurses should follow seven rights of medication administration that include the right individual, medication, dose, time, route, documentation and response. RN #2 stated she obtained this information several years ago from the national institute of health website.
On 3/22/22 at 11:42 AM, ASM #2 (Administrative Staff Member) the Director of Nursing, stated the facility uses [NAME] as the Standard of Practice.
Fundamentals of Nursing [NAME] and [NAME]- Ambler PA 2007 page 181 Nurses carry a great deal of responsibility for making sure that patients get the right drugs at the right time, in the right dose and by the right routes .this includes accurate documentation and explanation if doses are missed or not administered .
The facility's policy Medication Administration documented in part, Physician's Orders - Medications are administered in accordance with written orders of the attending physician. 2. Verify the medication label against the medication administration record for guest/resident name, time, drug, dose, and route. a. The nurse is responsible to read and follow precautionary instructions on prescription labels. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.
No further information was provided prior to exit.
References:
(1) Used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682134.html
(2) Administered by injection or as a nasal spray to reverse the effects of opioids especially in the emergency treatment of opioid overdose. This information was obtained from the website: https://www.merriam-webster.com/dictionary/naloxone.
3. The facility staff failed to follow orders for wound care for Resident #217.
On the most recent MDS (Minimum Data Set), a 5-day assessment with an ARD (Assessment Reference Date) of 9/9/21, Resident #217 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as being independent for eating and required limited to extensive assistance for all other areas of activities of daily living.
A physician's order dated 9/2/21 documented, Right shin skin prep (1) every shift.
A review of the September 2021 TAR (Treatment Administration Record) revealed this order was scheduled for each shift starting on the night shift on 9/2/21 and ended on day shift on 9/19/21 when the resident discharged . This accounted for a total of 50 opportunities of administration. Of these 50 opportunities, there were 5 opportunities that were not documented as being completed and/or refused.
A physician's order dated 9/6/21 documented Skin Prep to blister on lower right leg every shift every shift for Prevention.
A review of the September 2021 TAR revealed that this treatment was scheduled for each shift starting on evening shift on 9/6/21 and ended on day shift 9/19/21 when the resident discharged . This accounted for a total of 39 opportunities of administration. Of these 39 opportunities, there were 5 opportunities that were not documented as being completed and/or refused.
On 3/23/22 at 11:28 AM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that if the MAR has holes in it, she would assume it wasn't given or wasn't done.
A review of Resident #217's comprehensive care plan dated 9/2/21 revealed: Actual impairment to skin integrity r/t (related to) -trauma areas- left outer hand, right shin .Treatment to skin impairment per order.
A review of the facility policy, Physician's Orders was reviewed. This policy did not specifically document that physician's orders must be followed, however, it did document, Treatment rendered to a guest/resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges.
On 3/24/22 at approximately 11:30 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings.
No further information was provided by the end of the survey.
COMPLAINT DEFICIENCY
REFERENCES
1. Skin Prep - A liquid protective barrier wipe designed to form protective film to reduce friction during removal of tapes and films as well as prep skin for drainage tubes, external catheters, surrounding ostomy sites and adhesives formulated to help skin breathe so tape and film adheres better indicated for use on intact skin only.
Information obtained from https://www.medline.com/jump/product/x/Z05-PF32716#mrkDocumentation
4. The facility staff failed to follow the physician's order by giving a double dose of a nasal spray to Resident # 9 (R9).
On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 12/30/2021, the resident was coded as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions.
Observation was made of LPN (licensed practical nurse) #4 administering medications to R9 on 3/23/2022 at 8:15 a.m. LPN #4 administered all of the oral medications and then administered the nasal spray, Fluticasone Propionate (Flonase) Nasal Spray (used for the management of nasal symptoms of perennial nonallergic[sic] rhinitis) (1). LPN #4 administered two sprays in each nostril. After LPN #4 had finished administering the nasal spray, LPN #4 went back to the medication cart and started to sign out the medications on the MAR (medication administration record). When LPN #4 got to the entry for the administration of the nasal spray, they turned toward the surveyor and stated they made an error, and had given two sprays in each nostril instead of one in each nostril. When asked what they had to do next, LPN #4 stated they needed to contact the nurse practitioner about the error and notify the responsible party. When asked the process for administering medications, LPN #4 stated they had checked the resident's name, medication, dose prior to going into the room. LPN #4 stated they didn't know why they gave the two sprays, and that they were nervous.
The physician order dated 12/23/2021 documented, Flonase Suspension 50 MCG/ACT (micrograms per activation) 1(one) spray in both nostrils one time a day for allergies.
The nurse's note dated 3/23/2022 at 8:39 a.m. documented, Writer in room administering Flonase, writer gave two sprays in each nostril instead of one, writer notified NP (nurse practitioner) in facility, no new orders, will monitor guest for any changes.
The nurse's note dated, 3/24/2022 at 7:30 a.m. documented, RP (responsible party) made aware of med (medication) error and that no new orders were given by the NP.
Review of the comprehensive care plan dated 12/23/2021 failed to reveal information regarding the use of a nasal spray.
On 3/24/2022 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2 regarding following physician's orders for medication administration. RN #2 stated nurses should read the MAR (medication administration record), find the medication, read the MAR again, read the medication and double check the medication against the MAR. RN #2 stated nurses should follow seven rights of medication administration that include the right individual, medication, dose, time, route, documentation and response. RN #2 stated she obtained this information several years ago from the national institute of health website.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were made aware of the above concern on 3/23/2022 at 4:15 p.m.
No further information was obtained prior to exit.
References:
(1) This information was obtained from the package insert of the box for the medication, Fluticasone Propionate Nasal Spray by West-Ward Pharmaceuticals Corp.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review, facility document review, and staff interview, it was determined that the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review, facility document review, and staff interview, it was determined that the facility staff failed to ensure a resident was free of a significant medication error for one of 51 residents in the survey sample, Resident #16 (R16). On 11/02/2021 at 10:00 p.m. and on 11/03/2021at 6:00 a.m., facility staff overdosed Resident # 16 R16 by administering 5ml (five milliliters) of Methadone (1), which was ten times the physician ordered dose, resulting in (R16's) oxygen saturation dropping to 77% and requiring administration of Narcan (2). The resident was taken to the hospital for further interventions and monitoring. The deficient practice resulted in harm to the resident.
The findings include:
R16 was admitted to the facility with diagnoses that included but were not limited to: lung cancer, respiratory failure and a blood clot in the lungs.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/22/2021, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0400 coded R16 as frequently experiencing pain at a level of five out of 10 during the look back period.
On 03/22/22 at approximately 1:11 p.m., R16 stated that approximately four months ago they were given an overdose of methadone and were sent to the hospital.
The physician's orders for R16 documented in part, Methadone HCl (hydrochloride) Intensol Concentrate 10 MG(milligrams)/ML Give 0.5 ml orally every 8 (eight) hours for pain. Order Date: 11/02/2021 .Narcan Liquid 4 MG/0.1ML (milliliter) (Naloxone HCl) 0.1 ml in nostril STAT (immediately) for Sedation -Start Date11/03/2021.
The comprehensive care plan for R16 dated 06/15/2021 documented in part, R16 has pain r/t (related to): muscle weakness, Lung Cancer, Chronic Thromboembolic Pulmonary Hypertension ., Date Initiated: 06/15/2021 .Observe for side effects of pain medication. Date Initiated: 06/15/2021.
The facility's nurse's note dated 11/03/2021 documented, 7:25 a.m., Text: Med (medication) error noted during narcotic count at 7:15am. VS (vital signs) at that time 97.2 (temperature) -57 (pulse)-16 (respiration) -116/77 (blood pressure) O2 sat (oxygen saturation) 88-89% on 5L/min (five liters per minute) O2 via (by) NC (nasal cannula). Resident alert and responsive. UM (unit manager) notified of error and residents status. Hospice and MD (medical doctor) notified. New order for Narcan if O2 sat goes below 80%. CNA in room with resident. VS at 7:30 am 96.9-61-17-128/80 O2 sat 74%. Narcan given per order at 8:20am (a.m.). O2 sat increased to 87%. VS at 7:45am 97.1-60-18-130/86. MD in and stated to send resident to ER (emergency room) and increase O2 to 15L (liters) on non-rebreather mask. 911 called for transport. Resident becoming anxious- c/o (complaint of) being cold and shaky. VS at 8am 96.8-59-18-126/86 O2 sat 84%.Resident becoming restless. VS at 8:30am 97.1-71-18-127/88 O2 sat 91%. 911 in to transport at 8:50am. Family notified of residents condition and need to transport to hospital. Author: [Name of LPN (licensed practical nurse)] #2. Further review of the nurse's note revealed a handwritten noted that documented, Nurse during count stated I must have given 5ml instead of .5ml (0.5ml), and signed by LPN # 2.
The nurse's note dated 11/03/2021 at 8:36 a.m. documented, VS 97.2-57-16-116/77 O2 sat 88-89% on 5L/min via NC. O2 mask applied. O2 sat 93% but dropped to 77%. Narcaine [sic] given at 8:20am per MD order. O2 sat 91% but dropped to 77%. MD in and stated to send to ER (emergency room). Hospice notified. VS taken every 15 min. Resident alert and talking but slow. Voices no complaints at this time.
The facility form Analysis of Medication Event for R16 dated 11/03/2021 documented in part, Date of Event: 11-2-21, 11-3-21. Time of Event: 2200 (10:00 p.m.) 6:00 a.m. Medication Given: Methadone. Dosage Given: 5mL. Route: po (by mouth). Cause of Event: How did the event occur?: Nurse gave wrong dosage X2 (times two) 2200 & (and) 6:00 am. What is the actual effect of the event on the guest? Decrease O2 Sat rate. How was event discovered? During am count by off going nurse and on coming nurse. Name(s) and title(s) of employee(s) involved: [Name of Registered Nurse (RN) #3].
The facility's Controlled Medication Utilization Record for R16 documented in part, Methadone Intensol Concentrate 10 MG/1 (one)ML oral CONC (concentrate) 0.5 ml sublingually (under the tongue) three times daily for pain. Date: 11/2/21. Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL. Under Date: 11/3/21 it documented, Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL.
The Emergency Provider Report for R16 from [Name of Hospital] dated 11/03/2021 documented in part, Free Text HPI (history of present illness) Notes. Patient with history significant for end-stage lung cancer, COPD, asthma, CAD, HTN, presents to the emergency department for reports of accidental overdose on methadone. Patient is on hospice in resides at [Name of Nursing Home], at which a hospice nurse visit him, helps distances [sic] pain medication. Reportedly patient is on known concentration of methadone, however was supposed to receive 0.5mL this morning, rather he received 5mL accidentally per staff. He then became minimally responsive. EMS (emergency medical services) was called, Narcan was administered EN (unknown abbreviation) route was immediately brought the patient around. Patient upon arrival reports being diffuse widespread pain, feeling as though he is going to vomit, having diarrhea. Patient denies feeling drowsy or having difficulty breathing currently. No chest pain. No recent fevers. No other medical complaints at this time.
The Discharge Summary for R16 from [Name of Hospital] dated 11/04/2021 documented in part, Hospital Course. [AGE] year old with hx (history) of lung cancer ch (chronic history) resp (respiratory) failure on home O2 5lpm (liters per minute) was under Hospice care at SNF (skilled nursing facility) and was given accidental higher dose of methadone 5ml of intensol instead of 0.5ml and was noted to have AMS (altered mental status) and increase O2 needs, narcan given and pt (patient) was referred to ER, poison control was called by ER provider and was advised to be admitted for observation. HOV [Name of Hospice]) was called and pt will be admitted overnight as GIP (general inpatient) for monitoring. At time of my eval (evaluation) is awake and alert complain gof [sic] pain all over, I was able to switch pt to 5lpm O2 via NC. Pt was placed on monitoring and did well and will proceed with dc (discharge) back to SNF with HOV. Staff at SNF to exercise caution with use of narcotics.
On 03/23/2022 at approximately 12:10 p.m. an interview was conducted with LPN # 1 and LPN # 2, unit manager. When asked how the medication error was discovered LPN # 2 stated that when they were doing the medication count on 11/03/2021 for the 7:00 a.m. to 3:00 p.m. shift with RN #3, there was a discrepancy with the methadone. There was more was missing than should have been. LPN # 2 stated that RN #3 realized that [Name of R16] received too much methadone. When asked how much methadone had been administered to R16, LPN # 2 stated that they had received 5 milliliters instead of 0.5 milliliters. LPN # 2 stated that they checked [Name of R16's] vital signs, went back to the nurse's station and informed LPN # 1. LPN # 1 stated they informed LPN # 2 to call and notify hospice due to the fact that R16 was under hospice care, then they assigned a CNA (certified nursing assistant) in (R16's) room to monitor their oxygen saturation. LPN #1 further stated that they notified the physician and they gave an order and to monitor the oxygen saturation and for Narcan if the oxygen saturation dropped below 80%. When asked if the Narcan was used LPN #1 stated that (R16's) oxygen saturation dropped to 77% and that LPN # 2 administered the Narcan. LPN # 1 further stated that the physician was in the facility at that time, checked (R16's) vital signs and gave an order to have R16 sent to the hospital by 911 and that by the time the EMTs (emergency medical technicians) arrived (R16's) oxygen saturation was up to 84%. When asked to interview RN #3, LPN # 1 stated that [Name of RN # 3] returned the next day, was supervised during their medication administration, and has never return to the facility. When asked how a nurse ensures the physician's orders are followed for medication administration, LPN # 1 stated that if it is a narcotic they should triple check the narcotic book, with the physician's orders, with the medication and follow the seven rights of medication administration that include the right route, medication, dose, patient, time, documentation and response.
On 03/23/2022 at 12:45 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were informed of the above findings.
On 3/24/22 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding the facility process for when a medication error occurs. RN #2 stated the nurse should notify the nurse practitioner, notify the responsible party, monitor the resident, and follow orders provided by the nurse practitioner.
Review of the facility's documents for an action plan to correct this deficient practice revealed credible evidence that an in-service was conducted on 11/04/2021 for all licensed nurses. The in-service content addressed the facility's policy on medication administration to all RNs and LPNs, including the rights of medication administration. The credible evidence included documentation that management staff conducted medication administration observations with licensed nurse on 11/04/2021 and 11/05/2021. On 03/24/2022 at approximately 9:20 a.m., an interview was conducted with ASM # 1. When asked when the facility was in compliance regarding the in-service and medication administration observations, ASM # 1 stated that the facility was in compliance by 11/19/2021.
The pharmacy information sheet for methadone documented in part, Dosage Forms and Strengths. Oral concentrate: each mL contains 10 mg of Methadone hydrochloride. Under 10 OVERDOSAGE it documented in part, Clinical presentation: Acute overdose with methadone can be manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal- muscle flaccidity, cold and clammy skin, constricted pupils, and in some cases, pulmonary edema, bradycardia, hypotension, partial or complete airway obstruction, atypical snoring, and death. Marked mydriasis rather than miosis may be seen with hypoxia in overdose situations [see Clinical Pharmacology (12.2)]. In severe overdosage, particularly by the intravenous route, apnea, circulatory collapse, cardiac arrest, and death may occur.
Treatment of overdose: In case of overdose, priorities are the re-establishment of a patient abd protected airway and institution of assisted or controlled ventilation, if needed. Employ other supportive measures (including oxygen, vasopressors) in the management of circulatory shock and pulmonary edema as indicated. Cardiac arrest or arrhythmias will require advanced life support techniques. The opioid antagonists, Naxolone and Nalmefene, are specific antidotes to respiratory depression resulting from opioid overdose. For clinically significant respiratory or circulatory depression secondary to methadone overdose, administer an opioid antagonist. Opioid antagonists should not be administered in the absence of clinically significant respiratory or circulatory depression secondary to methadone overdose.
Because the duration of reversal would be expected to be less than the duration of action of methadone in Methadone Hydrochloride Intensol, carefully monitor the patient until spontaneous respiration is reliably reestablished. If the response to opioid antagonists is suboptimal or not sustained, administer additional antagonist as directed in the product's prescribing information.(3).
No further information was provided prior to exit.
Past noncompliance
References:
(1) Used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682134.html
(2) Administered by injection or as a nasal spray to reverse the effects of opioids especially in the emergency treatment of opioid overdose. This information was obtained from the website: https://www.merriam-webster.com/dictionary/naloxone.
(3) This information was obtained from the website: https://dailymed.nih.nih.gov.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide privacy and dignity to 1 of...
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Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide privacy and dignity to 1 of 51 residents in the survey sample, Resident #216.
The facility staff failed to maintain the Foley catheter bag in a manner to promote privacy and dignity for Resident #216.
The findings include:
On the most recent MDS (Minimum Data Set), an admission/5-day assessment with an ARD (Assessment Reference Date) of 12/10/21, Resident #216 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was not coded as having an indwelling catheter at that time.
A review of the clinical record revealed physician's orders dated 3/3/22 for the use of a Foley catheter.
On 3/22/22 at 2:28 PM, an observation was made of Resident #216. The Foley catheter bag was hanging on the side of the bed closest to the door, and was viewable from the door with no privacy bag covering it. Staff was in with the resident.
On 3/22/22 at 4:12 PM, another observation was made of Resident #216. The Foley bag was observed exactly as before, and there was staff in the room with the roommate.
On 3/24/22 at 10:00 AM, an interview was conducted with Resident #216. When asked how they felt about the catheter bag being uncovered and exposed, they stated: Why would you uncover it? When re-asked if having the Foley bag exposed so others can see it bothered them, they stated, I don't know why it would be exposed.
A review of the resident's comprehensive care plan dated 3/3/22 revealed, in part: At risk for urinary tract infection and catheter-related trauma: has Indwelling Catheter .Ensure the drainage bag is secured properly with a dignity cover in place.
On 3/23/22 at 11:28 AM, an interview was conducted with LPN #4 (Licensed Practical Nurse). When asked how the Foley catheter bag should be maintained, LPN #4 stated that it should be in a privacy bag.
The facility policy, Indwelling urinary catheter (Foley) care and management, was reviewed. This policy did not address maintaining the catheter bag in a manner that promotes privacy and dignity.
On 3/24/22 at approximately 11:30 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings.
No further information was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, facility document review and clinical record review, it was determined that the facility staff failed to facilitate a resident's right for self-determination ...
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Based on observation, resident interview, facility document review and clinical record review, it was determined that the facility staff failed to facilitate a resident's right for self-determination and choice for 1 of 51 residents in the survey sample, Resident #313.
Resident #313 (R313) verbalized the desire for bed rails. The facility staff failed to honor this preference and assess the resident for the use of bed rails.
The findings include:
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/22/21, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions.
A review of R313's clinical record revealed a nurse's note dated 12/15/21 that documented, Resident new admit .has voiced concerns that [R313] wants side rails (bed rails) on .bed .is alert and oriented .uses a walker to stand and pivot only. Metal brace to .leg but .refused to let nurse do a thorough skin assessment due to .being upset about side rails. Further review of R313's clinical record (including nursing assessments and therapy notes from 12/16/21 through 3/22/22) failed to reveal any bed rail assessments.
On 3/22/22 at 1:02 p.m., an interview was conducted with R313. The resident stated they wanted half bed rails for mobility. R313 further stated that they had voiced this to several staff members and was told that they could not have bed rails due to corporate policy. No bed rails were observed on the resident's bed.
On 3/23/22 at 11:57 a.m., an interview was conducted with OSM (other staff member) #3 (the rehab director). OSM #3 stated she reviewed R313's therapy notes and spoke to the physical therapist. OSM #3 stated the therapy staff worked with R313 on bed mobility and transfers as part of the plan of care. OSM #3 stated R313 would not have been able to roll over to access a bed rail when initially admitted and the resident is currently independent with mobility and transfers so there is no need for bed rails. OSM #3 stated this information was not documented nor was any request that R313 wanted bed rails.
On 3/23/22 at 12:56 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated some residents have assist bars (bed rails) if they are able to use them for maneuvering in bed such as for turning. RN #2 stated if a resident requests bed rails then nurses should complete a physical device evaluation to make sure bed rails are not a restraint and are safe for that resident to use, then create a work order for the bed rails to be put into place.
On 3/23/22 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern.
The facility document regarding residents' rights documented, (1) Dignity, Respect & Quality of Life. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 51 residents in t...
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Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 51 residents in the survey sample, Resident #35.
The facility staff failed to complete the BIMS (brief interview for mental status) assessment for Resident #35's (R35) quarterly MDS assessment with an ARD (assessment reference date) of 1/14/22.
The findings include:
Section B of R35's quarterly MDS assessment with an ARD of 1/14/22 coded the resident as being understood. Section C0100 documented the BIMS assessment should be conducted. All of the questions related to the BIMS assessment (C0200 through C0400) and the BIMS summary score were coded with dashes, indicating the areas were not assessed.
On 3/23/22 at 9:41 a.m., an interview was conducted with OSM (other staff member) #2 (the social services director). OSM #2 stated R35's BIMS interview should have been done by the ARD date but the other social worker was off sick and the BIMS, Got mixed in the shuffle. OSM #2 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing the BIMS assessment.
On 3/23/22 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern.
The CMS RAI manual documents the following:
C0100: Should Brief Interview for Mental Status Be Conducted?
Item Rationale
Health-related Quality of Life
·Most residents are able to attempt the Brief Interview for Mental Status (BIMS).
·A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance.
- Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis .
·Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method .
Coding Tips
·Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) .
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility staff failed to evidence completion of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 1 of 51 residents, Resident #62. The facility staff failed to complete a level 1 PASRR for Resident #62 who was admitted to the facility on [DATE].
The findings include:
Resident #62 was admitted to the facility with diagnoses that included but were not limited to psychosis, major depressive disorder and dementia with behavioral disturbance. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/11/2022, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired for making daily decisions.
Review of Resident #62's clinical record failed to evidence a level 1 PASRR.
On 3/22/2022 at approximately 5:17 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the Level 1 PASRR for Resident #62.
On 3/23/2022 at 2:53 p.m., an interview was conducted with OSM (other staff member) #2, the social services director. OSM #2 stated that the PASRR was a coordinated effort between social services and admissions. OSM #2 stated that admissions started the process and social services completed the assessment. OSM #2 stated that they were looking for the Level 1 PASRR for Resident #62.
On 3/24/2022 at 11:00 a.m., ASM #1 stated that they did not think that they were going to have a PASRR to provide for Resident #62.
On 3/23/2022 at 5:05 p.m., a request was made to ASM #1, the administrator for the facility policy regarding PASRR assessments.
On 3/24/2022 at 11:23 a.m., ASM #1, the administrator stated that the facility did not have a policy regarding the PASRR.
The document, COVID-19 Emergency Declaration Waivers updated 11/29/2021, documented in part on page 16, Waive Pre-admission Screening and Annual Resident Review (PASARR). CMS (Centers for Medicare and Medicaid Services) is waiving 42CFR 483.20(k), allowing nursing homes to admit new residents who have not received Level 1 or Level 2 Preadmission Screening. Level 1 assessments may be performed post-admission. On or before the 30th day of admission, new patients admitted to nursing homes with a mental illness (MI) or intellectual disability (ID) should be referred promptly by the nursing home to State PASARR program for Level 2 Resident Review . This information was obtained from the website: https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf
On 3/24/2022 at approximately 11:00 a.m., ASM #1, the administrator and RN (registered nurse) #2, unit manager were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for 1 of 51 reside...
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Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for 1 of 51 residents in the survey sample, Resident #316.
The facility staff failed to develop Resident #316's (R316) baseline care plan to include the use of oxygen.
The findings include:
R316's diagnoses included acute and chronic respiratory failure. R316's admission minimum data set assessment was not completed. A nursing comprehensive evaluation dated 3/18/22 documented R316 was alert and oriented to time, place and person. The evaluation further documented R316 received oxygen therapy at four liters per minute.
A review of R316's clinical record revealed a physician's order dated 3/18/22 for continuous oxygen at four liters per minute. A review of R316's baseline care plan dated 3/18/22 failed to document information regarding the resident's respiratory status or oxygen therapy.
On 3/22/22 at 3:13 p.m., 3/22/22 at 4:33 p.m. and 3/23/22 at 7:51 a.m., R316 was observed in the bed room, receiving oxygen at three and a half liters per minute.
On 3/23/22 at 12:56 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the baseline care plan is created based on the nursing comprehensive evaluation then tweaked when reviewed. RN #2 stated the baseline care plan should include the use of oxygen but the nurse has to click on a button to trigger the baseline respiratory care plan.
R316's nursing comprehensive evaluated dated 3/18/22 failed to reveal check marks to trigger the respiratory care plan.
On 3/23/22 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern.
The facility policy titled, Care Planning documented, 2. A Baseline Care Plan will be developed within 48 hours identifying any immediate needs, initial goals and interventions needed to provide effective and person-centered care.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to review and/or revise the comprehensive care plan after a fall on 1/12/22 for Resident #216.
On t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to review and/or revise the comprehensive care plan after a fall on 1/12/22 for Resident #216.
On the most recent MDS (Minimum Data Set), an admission/5-day assessment with an ARD (Assessment Reference Date) of 12/10/21, Resident #216 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions.
A review of the clinical record revealed a nurse's note dated 1/12/22 that documented, Writer called to residents room by staff stating that resident was in floor. Resident was observed sitting on [their] bottom in [their] bathroom. [They] was observed to have two wheelchair cushions in [their] wheelchair, with one hanging onto floor and the other secured to seat of wheelchair. No injuries noted at this time. Unsecured cushion taking from wheelchair. RP (responsible party) notified verbally. MD (medical doctor) notified.
A review of the comprehensive care plan dated 12/4/21 revealed, in part: [Resident #216] is at risk for fall related injury and falls R/T: pain episode, mobility deficit, psychotropic medication use. Further review of this care plan failed to reveal any new interventions shortly after the above fall on 1/12/22, or any evidence it was reviewed after the 1/12/22 fall.
A review of the fall incident report dated 1/12/22 revealed the resident was reaching for something and slipped out of the wheel chair, as resident had 2 cushions in the wheel chair. It further documented that the extra cushions were removed from the wheel chair. In addition, the incident report documented, New intervention after IDT (interdisciplinary team) review .guest to have only one wc (wheel chair) cushion. The box for Care plan/[NAME] Updated was not checked.
On 3/24/22 at 7:54 AM an interview was conducted with RN #1 (Registered Nurse) the Assistant Director of Nursing. She stated that the intervention documented on the incident report should have been added to the care plan.
On 3/24/22 at 8:44 AM, RN #1 followed up after reviewing the care plan further, and stated that the care plan was not updated.
On 3/24/22 at approximately 11:30 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings.
No further information was provided by the end of the survey.
Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the care plan for two of 51 residents in the survey sample, Residents #53 and #216.
The findings include:
1. For Resident #53 (R53), the facility staff failed to review and revise the care plan for a change in the resident's code status from a full code to a DNR (do not resuscitate).
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/31/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions.
The physician order dated 2/15/2022, documented, Do Not Resuscitate (No CPR - cardiopulmonary resuscitation).
The clinical record contained the form, Durable Do Not Resuscitate Order (DDNR) dated 11/8/2021.
The review of the comprehensive care plan dated 1/5/2022 documented in part, Need: [R53] is a full code .Facility will make attempts to sustain life in emergency situations.
An interview was conducted with OSM (other staff member) #2, the social services director, on 3/23/2022 at 1:05 p.m. When asked whose responsibility it is to update the care plan for a change in the code status, OSM #2 stated it could be social services, nursing or whomever gets notified of the change. The above physician order and DDNR were reviewed with OSM #2. When asked if the care plan should have been updated to reflect the physician order and the DDNR form, OSM #2 stated she would like to review this before responding. On 3/23/2022 at 3:09 p.m. OSM #2 stated (R53)'s care plan was updated on 2/14/2022 and the new order came in on 2/15/2022. The care plan failed to evidence the review date of 2/14/2022. OSM #3 stated there was a lack of awareness to change the care plan. When asked what the purpose of the care plan is, OSM #3 stated it tells the staff the most updated plan of care. When asked if (R53)'s care plan should have been updated, OSM #2 stated, yes.
The facility policy Care Planning documented in part, Policy: Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident representative, therapy staff as required and any other ancillary staff. Additional resources will also be utilized to ensure that any additional needs or risk areas are identified 9. The care plan and resident [NAME] will be updated on Admission, Quarterly, Annually and with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable as needed.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were made aware of the above concern on 3/23/2022 at 4:15 p.m.
No further information was obtained prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility document review it was determined that the facility s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide treatment to promote healing of a pressure injury for 1 of 51 residents in the survey sample, Resident #3. The facility staff failed to follow professional standards of care when providing treatment to Resident #3's pressure injury on 3/23/2022. LPN (licensed practical nurse) #1 was observed using one piece of gauze to clean off three separate pressure injuries located on Resident #3.
The findings include:
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section M documented Resident #3 having two Stage 4 pressure ulcers.
On 3/23/2022 at 9:47 a.m., an observation was made of ASM (administrative staff member) #6, wound physician, assessing the pressure injuries for Resident #3. After assessing and debriding the pressure injuries as needed, ASM #6 advised LPN #1 the treatment to be applied to the wounds and left the room. LPN #1 was observed to use a single four by four gauze pad to wipe off the wound to the left upper sacral area, then to the left ischium, and then to the right ischium prior to applying the prescribed treatments.
On 3/23/2022 at 10:25 a.m., an interview was conducted with LPN #1. LPN #1 stated that Resident #3 has three pressure injuries on their buttocks and each were treated as a separate wound. When asked about the observation on 3/23/2022 at 9:47 a.m., of using the one gauze to wipe off all three wounds, LPN #1 stated that they only had one gauze available and had turned the gauze corners for each wound so they did not touch. LPN #1 stated that they should have used a separate gauze to wipe off each wound to prevent any cross contamination between the wounds.
The physician orders for Resident #3 documented in part: Cleanse left ischium with normal saline. Apply Santyl and calcium alginate cover with dry dressing every day shift for wound. Order Date: 12/01/2021 .Cleanse right ischium with NS (normal saline), apply Medihoney cover with foam every day shift for wound. Order Date: 01/09/2022 .Sacrum: cleanse with NS, apply Medihoney and foam dressing. Every day shift. Order Date: 01/28/2022.
The comprehensive care plan for Resident #3 documented in part, [Resident #3] has an actual impaired skin integrity related to pressure injury. -left ischium (buttocks) chronic full thickness tissue loss wound with history of infections/surgical intervention. - removes wound care dressings. - pressure ulcer of right ankle, stage 4. Patient Plan- MRI (magnetic resonance imaging) ordered to r/o (rule out) osteomyelitis, MRI pending. - Start Augmentin while wait for MRI results. - Sacrum- partial loss of dermis (trauma from wound-care application removal), - right ischium - unable to stage. Date Initiated: 09/07/2021, Revision on: 03/23/2022.
On 3/22/22 at 11:42 AM, RN (registered nurse) #2, unit manager, stated the facility uses [NAME] as the Standard of Practice.
The facility policy Clean dressing change failed to document guidance on cleaning multiple wounds during dressing changes.
In Fundamentals of Nursing Made Incredibly Easy, [NAME], [NAME] & [NAME], 2007, page 428;
When cleaning, be sure to move from the least-contaminated area to the most-contaminated area. For a linear shaped wound, such as an incision, gently wipe from top to bottom in one motion, starting directly over the wound and moving outward. For an open wound, such as a pressure ulcer, gently wipe in concentric circles, again starting directly over the wound and moving outward. Us a separate gauze pad each time the wound is cleaned. Discard the gauze pad for each wiping motion, repeat the procedure until you've cleaned the entire wound. Dry the wound with 4 X 4 gauze pads, using the same procedure as for cleaning. Discard the used gauze pads in the plastic bag.
On 3/23/2022 at 4:35 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of operations were notified of the findings.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide respiratory services for three of 51 residents in the survey sample, Residents #1, #316 and #16.
The findings include:
1. The facility staff failed to store Resident #1's nebulizer in a sanitary manner.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/25/2022, the resident scored 15 of 15 on the BIMS (brief interview for mental assessment), indicating the resident is cognitively intact for making daily decisions. Section O documented Resident #1 receiving oxygen while a resident at the facility, and as receiving respiratory therapy 7 days during the assessment period.
On 3/22/2022 at approximately 1:20 p.m., an interview was conducted with Resident #1 in their room. Resident #1 was observed sitting in a wheelchair beside the bed. A nebulizer delivery device with mask attachment sat uncovered on top of a nebulizer machine on the nightstand behind Resident #1. When asked about the nebulizer mask, Resident #1 stated that they received medication for breathing through it. Resident #1 stated that the nurses provided the medication and removed the mask when it was complete and put the mask on the nightstand.
Additional observations of Resident #1's room on 3/22/2022 at 3:25 p.m. and 4:15 p.m., revealed the findings above.
The physician's orders dated 3/24/2022 for Resident #1 documented in part: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG(milligram)/3 ML (milliliter) 3 ml inhale orally two times a day for COPD (chronic obstructive pulmonary disease) before breakfast and before dinner. Order Date: 06/08/2021 .Perforomist Mobilization Solution 20 MCG (microgram)/2 ML (Formoterol Fumarate) 2 ml inhale orally via nebulizer two times a day for COPD. Order Date: 06/08/2021.
The eMAR (electronic medication administration record) dated 3/1/2022-3/31/2022 documented Resident #1 receiving the Ipratropium-Albuterol Solution on 3/22/2022 at 8:00 a.m. and the Perforomist nebulization solution on 3/22/2022 at 10:00 a.m.
The comprehensive care plan for Resident #1 dated 3/31/2021 documented in part, [Resident #1] has a potential for difficulty breathing and risk for respiratory complications R/T (related to): COPD, DHF (diastolic heart failure) . Date Initiated: 03/31/2021. Revision On: 02/25/2022.
On 3/23/2022 at approximately 1:00 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that nebulizers were changed once a week. LPN #1 stated that when the resident was done with the nebulizer treatment, the medication cup was emptied out and the nebulizer mask and delivery device were stored in a plastic bag. LPN #1 stated that the purpose of the bag was to keep the nebulizer from getting contaminated. LPN #1 was made aware of the observations in Resident #1's room on 3/22/2022 and stated that the nebulizer mask should have been covered and they would check it frequently.
On 3/22/22 at 11:42 AM, RN (registered nurse) #2, unit manager, stated the facility uses [NAME] as the Standard of Practice.
According to The Lippincott Manual of Nursing Practice 10th Edition, 2014, page 236, Procedure Guidelines 10-11 documented in part, Follow-up phase 1. Record medication used and description of secretions. 2. Disassemble and clean nebulizer after each use. Keep this equipment in the patient's room. The equipment is changed according to facility policy. Each patient has own breathing circuit (nebulizer, tubing and mouthpiece). Through proper cleaning, sterilization, and storage of equipment, organisms can be prevented from entering the lungs.
On 3/23/2022 at 4:35 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of operations were made aware of the findings.
No further information was provided prior to exit.
2. The facility staff failed to administer oxygen to Resident #316 (R316) per the physician prescribed rate of four liters.
R316's diagnoses included acute and chronic respiratory failure. R316's admission minimum data set assessment was not completed. A nursing comprehensive evaluation dated 3/18/22 documented R316 was alert and oriented to time, place and person. The evaluation further documented R316 received oxygen therapy at four liters per minute.
A review of R316's clinical record revealed a physician's order dated 3/18/22 for continuous oxygen at four liters per minute. A review of R316's baseline care plan dated 3/18/22 failed to document information regarding the resident's respiratory status or oxygen therapy.
On 3/22/22 at 3:13 p.m., 3/22/22 at 4:33 p.m. and 3/23/22 at 7:51 a.m., R316 was observed in the bed room, receiving oxygen at three and a half liters per minute as evidenced by the ball in the oxygen concentrator flowmeter positioned on the three and a half liter line.
On 3/23/22 at 12:56 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated nurses should verify physician's orders for oxygen and verify the correct amount of oxygen is being administered every shift. RN #2 stated the center of the ball in the oxygen concentrator flowmeter should pass through the four liter line for a physician's order of four liters. RN #2 stated R316 was currently receiving oxygen via a portable tank because the staff noticed the concentrator was not properly functioning about an hour before this interview.
On 3/23/22 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern.
The manufacturer's instructions for the oxygen concentrator documented, To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liter per minute) line prescribed.
No further information was presented prior to exit.
3a. Facility staff failed to maintain Resident # 16's oxygen flow rate at five liters per minute per the physician's orders.
Resident # 16 was admitted to the facility with diagnoses that included but were not limited to: lung cancer, respiratory failure and a blood clot in the lungs. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/22/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident #16 for Oxygen Therapy while a resident.
On 03/22/22 at approximately 1:02 p.m., an observation of Resident #16 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on oxygen concentrator revealed an oxygen flow rate between 4 and 5 liters per minute.
On 03/22/22 at approximately 4:00 p.m., an observation of Resident #16 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on oxygen concentrator revealed an oxygen flow rate between 4 and 5 liters per minute.
The physician order for Resident #16 documented, Oxygen at 5 L (liters) continuous every shift. Order Date: 06/16/2021. Start Date 06/16/2021.
The comprehensive care plan for Resident #16 dated 08/17/2021 documented in part, Need. Respiratory distress- remains on oxygen .Oxygen as ordered/emergent. Date Initiated: 08/17/2021,
On 03/23/2022 at approximately 2:10 p.m., an observation of Resident #16's oxygen concentrator and an interview was conducted with LPN (licensed practical nurse) #1. After reading the flow meter, LPN #1 stated, It's between four and five liters per minute. When asked how to read the oxygen flow rate on an oxygen concentrator, LPN #1 stated, The liter line goes through the middle of the ball. When asked what the flow rate should be LPN #1 stated, Five liters. When asked how often the oxygen flow rate is checked, LPN #1 stated, Every shift.
On 03/23/2022 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of clinical services and ASM #3, regional director of operations, were made aware of the above findings.
No further information was provided prior to exit.
3b. Facility staff failed to store Resident # 16's nebulizer mask in a sanitary manner.
On 03/22/22 at approximately 1:02 p.m., an observation of Resident #16's nebulizer mask revealed it was lying on Resident # 16's bed uncovered.
On 03/22/22 at approximately 4:00 p.m., an observation of Resident #16's nebulizer mask revealed it was lying on their bedside table uncovered.
On 03/23/22 at approximately 8:22 a.m., an observation of Resident #16's nebulizer mask revealed it was lying on their bedside table uncovered.
The physician order for Resident #16 documented in part, Albuterol Sulfate Nebulization Solution (2.5 MG (milligrams)/3ML (milliliters)) 0.083% (percent) 3 ml inhale orally two times a day related to malignant neoplasm of unspecified part of unspecified bronchus or lung .Order Date: 06/17/2021. Start Date 06/17/2021.
On 03/23/2022 at approximately 2:10 p.m., an interview was conducted with LPN #1. When informed of the observation of Resident # 16's nebulizer mask LPN #1 stated, It should be stored in a bag to keep it clean.
On 03/23/2022 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of clinical services and ASM #3, regional director of operations, were made aware of the above findings.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
3. The facility staff failed to administer the physician prescribed dose of 0.3 ml (milliliters) of the Pfizer COVID-19 vaccine to Resident #317 (R317). Instead, the facility staff administered 1.8 ml...
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3. The facility staff failed to administer the physician prescribed dose of 0.3 ml (milliliters) of the Pfizer COVID-19 vaccine to Resident #317 (R317). Instead, the facility staff administered 1.8 ml of the vaccine to the resident.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/20/21, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions.
A review of R317's clinical record revealed a physician's order dated 12/16/21 for 0.3 ml of the Pfizer COVID-19 vaccine. A medication error report dated 12/16/21 documented R317 was administered 1.8 ml of the Pfizer vaccine. The report further documented the physician was notified, ordered intravenous normal saline at 50 ml per hour for one hour and R317 had no adverse outcome.
On 3/24/22 at 8:03 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who administered the Pfizer vaccine to R317). LPN #3 stated on 12/16/21, he assisted the assistant director of nursing with administering the Pfizer vaccine to residents. LPN #3 stated he was unclear on the instructions for diluting the medication and he administered the incorrect dose to R317. LPN #3 stated he was given instructions for administering the vaccine but he wasn't aware the medication had to be diluted, and this was the first time he had drawn up the medication.
On 3/24/22 at 8:21 a.m., an interview was conducted with RN (registered nurse) #1 (the assistant director of nursing). RN #1 stated 12/16/21 was the first day she was charge at the facility and the director of nursing was not present. RN #1 stated on that day, she was completing multiple tasks and LPN #3 offered to assist with the Pfizer vaccines. RN #1 stated that at the time, she was not aware that the director of nursing usually drew up the vaccines and LPN #3 only administered them. LPN #3 stated she thought LPN #3 knew how to draw up the medication but she should have gone with him and observed.
On 3/24/22 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding unnecessary medications. RN #2 stated she assisted with the administration of COVID vaccines when they first became available. RN #2 stated she read the medication instructions and knew the medication needed to be diluted.
On 3/24/22 at 9:20 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #3 (the regional director of operations) were made aware of the above concern.
The manufacturer's instructions for the Pfizer vaccine administered to R317 documented, Each vial must be thawed and diluted prior to administration. Dilute the vial contents using 1.8 mL of sterile 0.9% Sodium Chloride Injection .
No further information was presented prior to exit.
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to prevent a resident from receiving an unnecessary medication for one five residents in the medication administration observation, Resident #9. The facility staffadministered a double dose of nasal spray to Resident #9.
The findings include:
On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 12/30/2021, the resident was coded as scoring a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions.
Observation was made of LPN (licensed practical nurse) #4 administering medications to R3 on 3/23/2022 at 8:15 a.m. LPN #4 administered all of the oral medications, and then administered the nasal spray, Fluticasone Propionate (Flonase) Nasal Spray (used for the management of nasal symptoms of perennial nonallergic[sic] rhinitis) (1). LPN #4 administered two sprays in each nostril. After LPN #4 had finished administering the nasal spray, LPN #4 went back to the medication cart and started to sign out the medications on the MAR (medication administration record). When LPN #4 reached the point for signing off the administration of the nasal spray, they turned toward the surveyor and stated they made an error, and had given two sprays in each nostril instead of one in each nostril. When asked what to do next, LPN #4 stated they needed to contact the nurse practitioner about the error and notify the responsible party. When asked the process for administering medications, LPN #4 stated they had checked the resident's name, medication, and dose prior to going into the room. LPN #4 stated they didn't know why they gave the two sprays, and that they stated they were nervous.
The physician order dated 12/23/2021 documented, Flonase Suspension 50 MCG/ACT (micrograms per activation) 1(one) spray in both nostrils one time a day for allergies.
The nurse's note dated 3/23/2022 at 8:39 a.m. documented, Writer in room administering Flonase, writer gave two sprays in each nostril instead of one, writer notified NP (nurse practitioner) in facility, no new orders, will monitor guest for any changes.
The nurse's note dated, 3/24/2022 at 7:30 a.m. documented, RP (responsible party) made aware of med (medication) error and that no new orders were given by the NP.
The Analysis of Medication Event dated, 3/23/2022, documented in part: R9's name, the date and time of the event: 3/23/2022 at 8:30 a.m. Medication: Flonase 50 mcg/act - 2 sprays each nostril administered. Type of event: dose. What is the actual effect of the event on the guest? No effect on the guest. How was the event discovered: Nurse realized immediately following administration. Nurse: [LPN #4]. Name of physician notified: [ASM (administrative staff member) # 4, the nurse practitioner] .Physician follow up orders/statement: No new orders. Name of Employee involved: [LPN #4]. What precautions have been taken to prevent similar event? Verbally educated nurse on seven rights of medication administration.
Review of the comprehensive care plan dated 12/23/2021 failed to reveal any information regarding the use of a nasal spray.
On 3/24/2022 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding unnecessary medications. RN #2 stated that in order to prevent excessive administration of nasal spray, the nurse should not squirt twice if the order is for one spray.
ASM #1, the administrator and ASM #3, the regional director of operations, were made aware of the above concern on 3/24/2022 at 9:18 a.m.
No further information was obtained prior to exit.
References:
(1) This information was obtained from the package insert of the box for the medication, Fluticasone Propionate Nasal Spray by West-Ward Pharmaceuticals Corp.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, clinical record review and facility document review, it was determin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed inspection was provided for one of 51 residents in the survey sample, Resident #412.
The facility staff failed to perform bed rail inspections for the use of positioning/assist bars for Resident #412.
The findings include:
Resident #412 was admitted to the facility with diagnoses that included but were not limited to: diabetes mellitus and morbid obesity. Resident #412's most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an assessment reference date of 3/14/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired.
On 3/22/22 at 1:20 PM and 3/23/22 at 8:20 AM , Resident #412 was resting in bed, with half rails raised on the left side of the bed.
A review of the physician order dated 3/21/22, revealed the following: One one/half side rail up as an enabler when in bed every shift.
A review of the clinical record revealed a Physical Device Evaluation form dated 3/21/22 for the use of assist bars. The form documented: Evaluation-reason for enabler device use: repositioning support, enable/increase bed mobility, enhance mobility and enable/increase independence. Consent was included on the form.
A review of Resident #412's comprehensive care plan dated 3/8/22 and revised 3/22/22, revealed: NEED: assistance with ADL's (activities of daily living) related to impaired mobility. INTERVENTIONS: one assist bar up as enabler to assist with turning and repositioning.
An interview was conducted on 3/22/22 at 1:20 PM with Resident #412. When asked if the rail was used, Resident #412 stated they use the rail to help turn in bed and to position themselves.
On 3/23/22 at approximately 10:00 AM, a request was made to administration for the bed rail inspections for all the beds in the facility.
On 3/23/22 at approximately 3:00 PM, OSM (other staff member) #12, the maintenance director provided the bed rail inspections. When asked about the inspections, OSM #12 stated the beds are inspected, and the list of rails is included. This is done by resident room /bed number. Upon review of the inspections, room [ROOM NUMBER]-P was not on the list.
On 3/23/22 at approximately 4:35 PM, ASM (administrative staff member) #1, the Administrator, and ASM #2, the Director of Nursing and ASM #3, the Regional Director of Ops were made aware of the above concern.
On 3/24/22 at approximately 9:30 AM, OSM #12 was asked to clarify the rail assessment list and to indicate where room [ROOM NUMBER]-P was assessed. OSM #12 stated that nursing must have put the rail on the bed recently. It was not on the list and had not been checked.
On 3/24/22 at 11:02 AM, ASM #1 stated, We do not have any policy related to bed inspections.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
3. The facility staff failed to implement the comprehensive care plan for the 24 hour foley output every evening shift for Resident #112.
Resident #112 was admitted to the facility with diagnosis that...
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3. The facility staff failed to implement the comprehensive care plan for the 24 hour foley output every evening shift for Resident #112.
Resident #112 was admitted to the facility with diagnosis that included but were not limited to: peripheral vascular disease and diabetes mellitus.
The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 3/1/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired.
A review of the comprehensive care plan dated 2/22/22 revealed the following, NEED: Indwelling suprapubic catheter related to neurogenic bladder. INTERVENTIONS: Observed, record, report to physician no urine output.
A review of the physician orders dated 2/23/22, revealed the following, 24 hour foley output every evening shift.
A review of Resident #112's TAR (treatment administration record) from 2/23/22-2/28/22, revealed missing documentation of 24 hour foley output every evening shift for four out of six evening shifts, 2/23, 2/24, 2/27 and 2/28/22.
A review of Resident #112's TAR (treatment administration record) from 3/1/22-3/23/22, revealed missing documentation of 24 hour foley output every evening shift for four out of 23 evening shifts, 3/2, 3/7, 3/9 and 3/21/22.
An interview on 3/23/22 at 4:05 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, the purpose of the care plan is to allow staff to know how to take care of the guests and to progress care. When asked if the care plan has been followed if there are blanks in treatment documentation, LPN #1 stated, No, it was not followed.
An interview was conducted with LPN #6 on 3/24/22 at 8:10 AM. When asked who documents foley output on the TAR, LPN #6 stated, the nurses document on the TAR. When asked what blanks on the TAR indicate, LPN #6 stated, if it's open and blank then it was not documented. When asked if there are blanks on the TAR, was the care plan followed, LPN #6 stated, No, it was not.
On 3/23/22 at approximately 4:35 PM, ASM (administrative staff member) #1, the Administrator, and ASM #2, the Director of Nursing and ASM #3, the Regional Director of Ops were made aware of the above concern.
No further information was provided prior to exit.
4. Facility staff failed to implement Resident # 16 comprehensive care plan for the administration of physician ordered oxygen at five liters per minute.
Resident # 16 was admitted to the facility with diagnoses that included but were not limited to: lung cancer, respiratory failure and a blood clot in the lungs. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/22/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident #16 as receiving oxygen while a resident.
On 03/22/22 at approximately 1:02 p.m., an observation of Resident #16 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between 4 and 5 liters per minute.
On 03/22/22 at approximately 4:00 p.m., an observation of Resident #16 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on oxygen the concentrator revealed an oxygen flow rate between 4 and 5 liters per minute.
The physician order for Resident #16 documented, Oxygen at 5 L (liters) continuous every shift. Order Date: 06/16/2021. Start Date 06/16/2021.
The comprehensive care plan for Resident #16 dated 08/17/2021 documented in part, Need. Respiratory distress- remains on oxygen .Oxygen as ordered/emergent. Date Initiated: 08/17/2021,
On 03/23/2022 at approximately 2:10 p.m., an observation of Resident #16's oxygen concentrator and interview was conducted with LPN (licensed practical nurse) #1. After reading the flow meter, LPN #1 stated, It's between four and five liters per minute. When asked what the flow rate should be LPN #1 stated, Five liters. When asked to describe the purpose of a care plan LPN #1 stated, It tells how to take care of the guest and tells their progress. After reviewing Resident # 16's comprehensive care plan, LPN #1 was asked if the care plan was being followed for the administration of Resident # 16's oxygen. LPN #1 stated No
On 03/23/2022 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of clinical services and ASM #3, regional director of operations, were made aware of the above findings.
No further information was provided prior to exit.
Based on observation, resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement a comprehensive care plan for 5 of 51 residents in the survey sample; Residents #216, #217, #112, and #16.
The findings include:
1. The facility staff failed to follow the comprehensive care plan for providing privacy of a Foley catheter drainage bag for Resident #216.
On the most recent MDS (Minimum Data Set), an admission/5-day assessment with an ARD (Assessment Reference Date) of 12/10/21, Resident #216 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was not coded as having an indwelling catheter at that time.
A review of the clinical record revealed physician's orders dated 3/3/22 for the use of a Foley catheter.
On 3/22/22 at 2:28 PM, an observation was made of Resident #216. The Foley catheter bag was hanging on the side of the bed closest to the door, and was viewable from the door with no privacy bag covering it. Staff was in with the resident.
On 3/22/22 at 4:12 PM, another observation was made of Resident #216. The Foley bag was observed exactly as before, and there was staff in the room with the roommate.
On 3/24/22 at 10:00 AM, an interview was conducted with Resident #216. When asked how they felt about the catheter bag being uncovered and exposed, they stated: Why would you uncover it? When re-asked if having the Foley bag exposed so others can see it bothered them, they stated, I don't know why it would be exposed.
A review of the resident's comprehensive care plan dated 3/3/22 revealed, in part: At risk for urinary tract infection and catheter-related trauma: has Indwelling Catheter .Ensure the drainage bag is secured properly with a dignity cover in place.
On 3/23/22 at 11:28 AM, an interview was conducted with LPN #4 (Licensed Practical Nurse). When asked how the Foley catheter bag should be maintained, LPN #4 stated that it should be in a privacy bag. When asked if the catheter bag is uncovered and the care plan documented to cover the bag for dignity, was the care plan being followed, LPN #4 stated it was not.
The facility policy, Care Planning was reviewed. This policy documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing and mental and psychosocial needs
On 3/24/22 at approximately 11:30 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings.
No further information was provided by the end of the survey.
2. The facility staff failed to follow the comprehensive care plan for providing wound care for Resident #217.
On the most recent MDS (Minimum Data Set), a 5-day assessment with an ARD (Assessment Reference Date) of 9/9/21, Resident #217 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as being independent for eating and required limited to extensive assistance for all other areas of activities of daily living.
A physician's order dated 9/2/21 documented, Right shin skin prep (1) every shift.
A review of the September 2021 TAR (Treatment Administration Record) revealed this order was scheduled for each shift starting on the night shift on 9/2/21 and ended on day shift on 9/19/21 when the resident discharged . This accounted for a total of 50 opportunities of administration. Of these 50 opportunities, there were 5 opportunities that were not documented as being completed and/or refused.
A physician's order dated 9/6/21 documented Skin Prep to blister on lower right leg every shift every shift for Prevention.
A review of the September 2021 TAR revealed that this treatment was scheduled for each shift starting on evening shift on 9/6/21 and ended on day shift 9/19/21 when the resident discharged . This accounted for a total of 39 opportunities of administration. Of these 39 opportunities, there were 5 opportunities that were not documented as being completed and/or refused.
A review of the comprehensive care plan for Resident #217 revealed one dated 9/2/21 for [Resident #217] has Actual impairment to skin integrity r/t (related to) -trauma areas- left outer hand, right shin. This care plan included an intervention dated 9/3/21 for Treatment to skin impairment per order.
On 3/23/22 at 11:28 AM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that if the MAR has holes in it, she would assume it wasn't given or wasn't done. When asked if the care wasn't done and the care plan documented to provide the care as ordered, was the care plan being followed, LPN #4 stated it was not.
On 3/24/22 at approximately 11:30 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.
COMPLAINT DEFICIENCY
References:
1. Skin Prep - A liquid protective barrier wipe designed to form protective film to reduce friction during removal of tapes and films as well as prep skin for drainage tubes, external catheters, surrounding ostomy sites and adhesives formulated to help skin breathe so tape and film adheres better indicated for use on intact skin only.
Information obtained from https://www.medline.com/jump/product/x/Z05-PF32716#mrkDocumentation
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 1 of 51 residents in t...
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Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 1 of 51 residents in the survey sample; Resident #80. The facility staff failed to clarify physician's orders regarding parameters for the administration of PRN (as-needed) pain medication for Resident #80.
The findings include:
On the most recent MDS (Minimum Data Set), an admission assessment with an ARD (Assessment Reference Date) of 2/28/22, Resident #80 scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as requiring supervision to total assistance for activities of daily living.
A review of the clinical record revealed a physician's order dated 2/21/22 for Tramadol (1) Tablet 50 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain.
A review of the clinical record also revealed a physician's order dated 2/21/22 for Acetaminophen (2) Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for pain or fever.
The above orders did not contain any parameters on when to give which one for pain, i.e., what pain level on a scale of 1 to 10 to give the Tramadol and what pain level to give the Acetaminophen.
A review of the March 2022 MAR (Medication Administration Record) revealed the resident was administered the Acetaminophen a total of 30 times, with a documented pain scale ranging 1 to 9. The pain scale that was documented was as follows: 1 time as 1; 1 time as 4; 11 times as 5; 13 times as 6; 3 times as 7; 1 time as 9. Further review revealed the resident was administered the Tramadol a total of 38 times, with a documented pain scale ranging 1 to 9. The pain scale that was documented was as follows: 1 time as 4; 16 times as 5; 13 times as 6; 6 times as 7; 1 time as 8; 1 time as 9. The MAR reflected that both medication options were frequently used for the same pain levels, as there were no parameters directing when to use which medication.
On 3/23/22 at 11:28 AM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that usually there would be a parameter in the order. She stated that if the order did not have a parameter, then to use nursing judgement for a pain scale on which one to give.
On 3/24/22 at 8:44 AM an interview was conducted with RN #1 (Registered Nurse) the Assistant Director of Nursing. She stated that it is at the provider's (physician) discretion whether or not to set parameters. She stated when in doubt, call the doctor, and that best practice would be to call the doctor and clarify the order because it should have a parameter.
On 3/24/22 at 9:00 AM an interview was conducted with RN #2. She stated that the order should be clarified, and that nurses should not be making the judgement.
A review of the facility policy, Pain Management was conducted. This policy did not document ensuring or clarifying that physician's orders for as-needed pain medication included parameters.
On 3/24/22 at approximately 11:30 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings.
No further information was provided by the end of the survey.
REFERENCES
1. Tramadol is used to relieve moderate to moderately severe pain.
Information obtained from https://medlineplus.gov/druginfo/meds/a695011.html
2. Acetaminophen is used to relieve mild to moderate pain.
Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to prepare food in a manner that was p...
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Based on observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to prepare food in a manner that was palatable for meal enjoyment.
The findings include:
On 3/22/22 at 5:05 PM, the dinner tray line service was observed. The temperatures were checked of each food item by OSM #13 (Other Staff Member) the dietary cook, utilizing a facility thermometer. The food temperatures were as follows:
Regular meal:
Pulled Pork BBQ 185
3-bean cooked salad 185
Potato wedge fries 190
Alternate meal items:
Hot dogs 177
Peas 176
Chicken [NAME] 175
Puree meal items:
Mashed potatoes 161
Puree chicken 175
Puree mix veggies 172
On 3/22/22 at 6:10 PM as the last service cart was being prepared, a test tray was requested from OSM #13. On 3/22/22 at 6:17 the service cart left the kitchen and was delivered to the 700 unit. The cart arrived to the unit at 6:20 PM,
On 3/22/22 at 6:32 PM, once all residents were served, OSM #10 (the Dietary Manager), pulled each test tray from the cart and checked the temperatures with a facility thermometer. The temperatures were as follows:
Regular meal:
Pulled Pork BBQ 132 degrees (a 54 degree drop)
3-bean cooked salad 115 degrees (a 70 degree drop)
Potato wedge fries 120 degrees (a 70 degree drop)
Alternate meal items:
Hot dogs 123 degrees (a 54 degree drop)
Peas 121 degrees (a 55 degree drop)
Chicken [NAME] 113 degrees (a 62 degree drop).
Puree meal items:
Mashed potatoes 118 degrees (a 43 degree drop)
Puree chicken 117 degrees (a 58 degree drop)
Puree mix veggies 117 degrees (a 55 degree drop)
On 3/22/22 at 6:40 PM, two surveyors and OSM #10 taste tested each food item. All agreed that each of the 3 pureed items and chicken alfredo were bland to taste and were room temperature and were not hot for meal enjoyment.
On 3/23/22 at approximately 2:12 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings.
On 3/23/22 at 5:05 PM a policy list was provided to ASM #1 (Administrative Staff Member) the Administrator. A policy for food palatability was requested on this list.
On 3/24/22 at 11:23 AM ASM #1 stated that there was not a policy for food palatability.
No further information was provided by the end of the survey.
COMPLAINT DEFICIENCY
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a complete and accurate medical record for three of 51 residents ...
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Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a complete and accurate medical record for three of 51 residents in the survey sample, Resident #112, Resident #416 and Resident #3.
The findings include:
1. A. The facility staff failed to document the 24 hour Foley output for Resident #112, per physician's order.
Resident #112 was admitted to the facility with diagnosis that included but were not limited to: peripheral vascular disease and diabetes mellitus. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 3/1/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired.
A review of the comprehensive care plan dated 2/22/22 revealed the following, NEED: Indwelling suprapubic catheter related to neurogenic bladder .Observe, record, report to physician no urine output.
A review of the physician orders dated 2/23/22, revealed the following: 24 hour Foley output every evening shift.
A review of Resident #112's TAR (treatment administration record) from 2/23/22-2/28/22, revealed missing documentation of 24 hour Foley output every evening shift for four out of six evening shifts, 2/23, 2/24, 2/27 and 2/28/22.
A review of Resident #112's TAR (treatment administration record) from 3/1/22-3/23/22, revealed missing documentation of 24 hour Foley output every evening shift for four out of 23 evening shifts, 3/2, 3/7, 3/9 and 3/21/22.
An interview was conducted on 3/23/22 at 4:05 PM with LPN (licensed practical nurse) #1. When asked if blanks on the TAR indicate a complete and accurate medical record, LPN #1 stated, no, that is not a complete and accurate medical record if there are holes in the documentation.
An interview was conducted with LPN #6 on 3/24/22 at 8:10 AM. When asked what blanks on the TAR indicate, LPN #6 stated if record is blank, then the care was not documented. When asked if the blanks indicate a complete and accurate medical record, LPN #6 stated, no, if there are blanks, it is not complete.
On 3/23/22 at approximately 4:35 PM, ASM (administrative staff member) #1, the Administrator, and ASM #2, the Director of Nursing and ASM #3, the Regional Director of Operations were made aware of the above concern.
According to the facility's Medical Records Management policy dated 1/31/22, revealed the following, Medical records must be complete, accurately documented, readily accessible, systematically organized, and maintained in a safe and secure environment.
No further information was provided prior to exit.
1. B. The facility staff failed to document physician ordered treatment for a skin tear to Resident #112's left lower extremity.
A review of the comprehensive care plan dated 2/22/22 revealed the following: NEED: Actual impaired skin integrity left lower calf .Treatment as ordered.
A review of the physician orders dated 2/22/22, revealed the following: Left lower extremity: apply Bactroban over skin tear, apply nonstick dressing, and change daily every day shift. Order revised on 3/1/22 to change time of treatment to every evening shift.
A review of Resident #112's TAR (treatment administration record) from 2/23/22-2/28/22, revealed missing documentation of left lower extremity treatment for three out of six day shifts, 2/23, 2/24 and 2/26/22.
A review of Resident #112's TAR (treatment administration record) from 3/1/22-3/23/22, revealed missing documentation of left lower extremity treatment for two out of 23 evening shifts, 3/2 and 3/20/22.
An interview was conducted on 3/23/22 at 4:05 PM with LPN (licensed practical nurse) #1. When asked if blanks on the TAR indicate a complete and accurate medical record, LPN #1 stated, no, that is not a complete and accurate medical record if there are holes in the documentation.
An interview was conducted with LPN #6 on 3/24/22 at 8:10 AM. When asked what blanks on the TAR indicate, LPN #6 stated if record is blank, then the care was not documented. When asked if the blanks indicate a complete and accurate medical record, LPN #6 stated, no, if there are blanks, it is not complete.
On 3/23/22 at approximately 4:35 PM, ASM (administrative staff member) #1, the Administrator, and ASM #2, the Director of Nursing and ASM #3, the Regional Director of Operations were made aware of the above concern.
No further information was provided prior to exit.
2. A. The facility staff failed to document treatment of Resident #416's diabetic ulcer.
Resident #416 was admitted to the facility with diagnoses that included, but were not limited to: peripheral vascular disease, popliteal-tibial bypass right leg and diabetes mellitus. The most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an ARD (assessment reference date) of 6/22/21, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired.
A review of the comprehensive care plan dated 6/15/21 revealed the following: NEED: Actual impairment to skin integrity related to diabetes and below knee popliteal to distal posterior tibial artery bypass graft and debridement right foot wound .Treatment to skin impairment per order.
A review of the physician orders dated 6/16/21 revealed the following: Right lateral foot: cleanse with normal saline, cover with Medihoney and dry dressing every day shift.
A review of Resident #416's TAR (treatment administration record) from 6/16/21-6/30/21, revealed missing documentation of five out of twelve day shifts, 6/18, 6/19, 6/23, 6/26 and 6/29/21. Treatment was discontinued 6/30/21 as diabetic wound was resolved.
An interview was conducted on 3/23/22 at 4:05 PM with LPN (licensed practical nurse) #1. When asked if blanks on the TAR indicate a complete and accurate medical record, LPN #1 stated, no, that is not a complete and accurate medical record if there are holes in the documentation.
An interview was conducted with LPN #6 on 3/24/22 at 8:10 AM. When asked what blanks on the TAR indicate, LPN #6 stated if record is blank, then the care was not documented. When asked if the blanks indicate a complete and accurate medical record, LPN #6 stated, no, if there are blanks, it is not complete.
On 3/23/22 at approximately 4:35 PM, ASM (administrative staff member) #1, the Administrator, and ASM #2, the Director of Nursing and ASM #3, the Regional Director of Ops were made aware of the above concern.
No further information was provided prior to exit.
2. B. The facility staff failed to document treatment on Resident #416's right leg incisions.
A review of the comprehensive care plan dated 6/15/21 revealed the following: NEED: Actual impairment to skin integrity related to diabetes and below knee popliteal to distal posterior tibial artery bypass graft and debridement right foot wound .Treatment to skin impairment per order.
A review of the physician orders dated 6/29/21, revealed the following Cleanse with normal saline, pat dry cover with Xeroform and cover with dry gauze every other day for wound care.
A review of Resident #416's TAR (treatment administration record) from 6/16/21-6/30/21, revealed missing documentation of two out of four day shifts, 7/5 and 7/7/21. Resident was discharged home on 7/9/21.
An interview was conducted on 3/23/22 at 4:05 PM with LPN (licensed practical nurse) #1. When asked if blanks on the TAR indicate a complete and accurate medical record, LPN #1 stated, no, that is not a complete and accurate medical record if there are holes in the documentation.
An interview was conducted with LPN #6 on 3/24/22 at 8:10 AM. When asked what blanks on the TAR indicate, LPN #6 stated if record is blank, then the care was not documented. When asked if the blanks indicate a complete and accurate medical record, LPN #6 stated, no, if there are blanks, it is not complete.
On 3/23/22 at approximately 4:35 PM, ASM (administrative staff member) #1, the Administrator, and ASM #2, the Director of Nursing and ASM #3, the Regional Director of Ops were made aware of the above concern.
No further information was provided prior to exit.
3. The facility staff failed to maintain a complete and accurate medical record documenting treatment to a pressure injury for Resident #3.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section M documented Resident #3 having two Stage 4 pressure ulcers.
The physician orders for Resident #3 documented in part,
- Cleanse left ischium with normal saline apply Santyl and calcium alginate cover with dry dressing every day shift for wound. Order Date: 12/01/2021.
- Cleanse right ischium with NS (normal saline), apply Medihoney cover with foam every day shift for wound. Order Date: 01/09/2022.
- Sacrum: cleanse with NS, apply Medihoney and foam dressing. Every day shift. Order Date: 01/28/2022.
- right ankle- cleanse with normal saline, pat dry, cover with Santyl and dry dressing every day shift for wound. Order Date: 11/12/2021.
The eTAR (electronic treatment administration record) dated 1/1/2022-1/31/2022 failed to evidence documentation for the following treatments on the following dates:
- Cleanse left ischium with normal saline apply Santyl and calcium alginate cover with dry dressing every day shift for wound. On 1/3/2022, 1/5/2022, 1/11/2022, 1/12/2022, and 1/18/2022.
- Cleanse right ischium with NS (normal saline), apply Medihoney cover with foam every day shift for wound. On
- Sacrum: cleanse with NS, apply Medihoney and foam dressing. On 1/3/2022, 1/5/2022, 1/11/2022, 1/12/2022, and 1/18/2022.
- right ankle- cleanse with normal saline, pat dry, cover with Santyl and dry dressing every day shift for wound. On 1/3/2022, 1/5/2022, 1/11/2022, 1/12/2022, and 1/18/2022.
The eTAR dated 2/1/2022-2/28/2022 failed to evidence documentation for the following treatments on the following dates:
- Cleanse left ischium with normal saline apply Santyl and calcium alginate cover with dry dressing every day shift for wound. On 2/13/2022 and 2/24/2022.
- Cleanse right ischium with NS (normal saline), apply Medihoney cover with foam every day shift for wound. On 2/13/2022 and 2/24/2022.
- Sacrum: cleanse with NS, apply Medihoney and foam dressing. On 2/13/2022 and 2/24/2022.
- right ankle- cleanse with normal saline, pat dry, cover with Santyl and dry dressing every day shift for wound. On 2/13/2022 and 2/24/2022.
The eTAR dated 3/1/2022-3/31/2022 failed to evidence documentation for the following treatments on the following dates:
- Cleanse left ischium with normal saline apply Santyl and calcium alginate cover with dry dressing every day shift for wound. On 3/5/2022, 3/6/2022, 3/14/2022 and 3/21/2022.
- Cleanse right ischium with NS (normal saline), apply Medihoney cover with foam every day shift for wound. On 3/5/2022, 3/6/2022, 3/14/2022 and 3/21/2022.
- Sacrum: cleanse with NS, apply Medihoney and foam dressing. On 3/5/2022, 3/6/2022, 3/14/2022 and 3/21/2022.
- right ankle- cleanse with normal saline, pat dry, cover with Santyl and dry dressing every day shift for wound. On 3/5/2022, 3/14/2022 and 3/21/2022.
On 3/23/2022 at 3:20 p.m., an interview was conducted with LPN #1. LPN #1 stated that pressure injury treatments were documented on the eTAR after they were completed. LPN #1 stated that blanks on the eTAR meant that the nurse probably got busy and forgot to sign off that they did the treatment. LPN #1 stated the medical record was not complete when there were blanks on the eTAR.
On 3/23/2022 at 4:35 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of operations were notified of the findings.
No further information was provided prior to exit.
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, staff interview, and facility document review, it was determined that the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens.
Th...
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Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens.
The findings include:
On 3/22/22 at 11:54 AM, the Kitchen tour was conducted with OSM #10 (Other Staff Member) the Dietary Manager. The following was noted:
At 11:56 AM, food residue was observed on the meat slicer. When asked about this, OSM #10 stated that the meat slicer was supposed to be clean and ready to use, and should not have residue on it.
At 12:00 PM, in the walk-in freezer, the following was observed: a box of meatless meatballs, a box of veggie chicken nuggets, a box of veggie burger patties, and a box of beef and pepper patties were all unsealed and exposed to the freezer environment. When asked about this, OSM #10 stated, How should the bags be sealed?
At 12:03 PM, the reach-in fridge was noted to contain a plastic resealable style bag of smoked deli ham, which was opened with the ham exposed to the refrigerator environment. When asked about this, OSM #10 stated that the bag should not be open.
At 12:06 PM the mixer was observed with a plastic bag covering over it. The bag was noted to have a damp brown substance on the inside of plastic covering, touching the mixer, and in bottom of the mixer bowl was a nickel sized drip of a wet brown substance. When asked about this, OSM #10 stated that the mixer was supposed to be clean and ready to use, and should not have residue on it.
At 12:12 PM, the 6-eye gas stove was noted with large loose chunk of burnt food residue on the back center eye, and burnt black and yellow residue appearing like cheese on the front center eye. Crumbs and burnt/charred residue was all over the top. When asked about this, OSM #10 stated the stove is cleaned every Monday (this observation was on Tuesday). When asked if food should be prepared on a stove with burnt food residue all over it, she stated no.
The facility policy, Dietary Cleaning and Sanitation was reviewed. This policy documented, It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination .The Dietary Manager or Dietitian will inspect the kitchen thoroughly to ensure cleaning schedules are completed as assigned.
The facility policy, Food Purchasing and Storage was reviewed. This policy documented, .All food items in refrigerators will be properly dated, labeled, and placed in containers with lids, will be wrapped, or stored in sealed food storage bags (See Cold Storage Chart). All frozen food will be dated, labeled and wrapped or sealed. Moisture-proof, tight-fitting materials will be used to prevent freezer burn .
On 3/23/22 at approximately 2:12 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings.
No further information was provided by the end of the survey.
Mar 2019
19 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, staff interview, facility document review and clinical record review, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to serve food in a manner to promote resident dignity for one of 53 residents in the survey sample, Resident # 264.
The facility staff failed to serve food in a manner to promote dignity in the facility's main dining room. Resident # 264 waited twenty-two minutes to receive her lunch meal, after her tablemate was served and eating the lunch meal.
The findings include
Resident # 264 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fractured right hip and swallowing difficulty. Resident # 264's MDS (minimum data set) was not due to be completed at the time of the survey.
The facility's nursing admission assessment dated [DATE] documented Resident # 264 was orientated to person, non-weight bearing and totally dependent of staff for transfers and toileting.
The baseline care plan for Resident # 264 dated 03/11/2019 documented, ADL (activities of daily living) Functional / Rehab (rehabilitation) Potential documented, Bathing/Hygiene w/assist (with assistance) of 1 (one) (staff member); Dressing/grooming w/assist of 1; Eating w/assist of 1; Toileting w/assist of 1; Ambulation/transferring w/assist of 2 (two) (staff members). Under Nutritional Status / Diet it documented, Diet as ordered: Full Liquid.
On 03/12/19 at 12:10 p.m., an observation was conducted of the facility's main dining room. Observation of Resident # 264 revealed she was sitting at a table in the dining room across the table from another resident and their family member. At approximately 12:15 p.m., the resident sitting opposite of Resident # 264 received her meal and began eating with assistance from their family member. Observation of Resident # 264 revealed she remained at the table while the other resident was eating and did not receive her meal until 12:37, twenty-two minutes later.
On 03/13/19 at 11:18 a.m., an interview was conducted with CNA (certified nursing assistant) # 6. When asked about Resident # 264 not being served her lunch at the same time the other resident at her table received her lunch, CNA # 6 stated, I not real familiar with (Resident # 264). Yesterday in the dining room was the first time I saw her. When asked to describe the procedure for serving residents who are at the same table for a meal, CNA # 6 stated, We serve everybody at the same table at the same time. When asked why that procedure is followed, CNA # 6 stated, Its's not good to have one person eating and everyone else watching. When asked if this was dignified for Resident # 264 to wait for her meal while the other resident at the table was eating, CNA # 6 stated, No, it is dignified to have everyone eating together. When asked how it may make someone feel, having to wait for their meal, while someone else at the table is already eating, CNA # 6 stated, It could make them feel uncomfortable, like we forgot them and that they're not going to eat.
On 03/13/19 at 3:11 p.m., an interview was conducted with OSM (other staff member) # 15, the acting dietary manager. When informed of the observation on 03/12/19 during lunch of Resident # 264 not being served her meal at the same time as the other resident at the same table, and waiting for twenty-two minutes for her meal, OSM # 15 stated, They should not have to wait. The resident was supposed to receive her meal in her room and she was in the dining room. It still should have not taken that long. OSM # 15 was asked to describe the process for serving residents seated at the same table. OSM # 15 stated, When serving the tables, when the first resident is served and they (staff/aides) go to get the next tray for the resident at the table and saw it wasn't there, the aide should have notified the kitchen right away, we could have looked up the diet order and got the tray in a shorter period of time.
The facility's policy Fine Dining/Restaurant-Style Dining Overview documented, 12.
All guest seated at the same table shall be served meals at the same time.
On 03/13/19 at approximately 5:20 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing and ASM # 3, regional director of operations were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for two of 53 residents in the survey sample, Residents #87 and #89.
1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to implement the abuse policy for reporting and completing a thorough investigation of the allegation.
2. The facility staff failed to implement the abuse policy for reporting a resident-to-resident altercation when Resident # 89 received a scratch under their eye on 12/07/18.
The findings include:
1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to implement the abuse policy for reporting and completing a thorough investigation of the allegation.
Resident #37 was admitted to the facility on [DATE]. Resident #37's diagnoses included but were not limited to high blood pressure, major depressive disorder and delusional disorders. Resident #37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/30/19, coded the resident as being cognitively intact. Section G coded Resident #37 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene.
Resident #87 was admitted to the facility on [DATE]. Resident #87's diagnoses included but were not limited to diabetes, high blood pressure and a fractured right arm. Resident #87's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/28/19, coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #87 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene.
On 3/12/19 at 1:53 p.m., an interview was conducted with Resident #37. Resident #37 stated the facility CNAs (certified nursing assistants) were abusive. Resident #37 stated that within the last couple of months, a CNA was in bed with Resident #87 (former roommate). Resident #37 stated the CNA's head was at the level of Resident #87's titties. Resident #37 stated the CNA was raping Resident #87. When asked if she had reported this information to the facility staff, Resident #37 stated she reported this to the social worker, a nurse and a CNA.
On 3/12/19 at 2:08 p.m. (immediately after the interview with Resident #37), the above allegation was reported to ASM (administrative staff member) #1 (the administrator). ASM #1 stated he was aware of the allegation and would provide additional information.
On 3/13/19 at 4:06 p.m., an interview was conducted with ASM #1. ASM #1 stated Resident #37 reported an allegation of rape to the former social worker after Resident #37 was told she was getting a new roommate. ASM #1 stated the social worker interviewed Resident #37 and Resident #37 stated she did not witness the rape but Jesus told her. ASM #1 stated the unit manager interviewed the CNA who allegedly raped Resident #87 and interviewed the resident's son who did not have any concerns. When asked if other staff was interviewed or if Resident #87 was assessed after Resident #37 voiced the allegation, ASM #1 stated Resident #37 stated the alleged rape occurred less than a month after that date but could not remember a date or time. When asked about the facility process for investigating a rape allegation, ASM #1 stated in this case, Resident #37 reported the alleged rape did not occur that day so staff reviewed past skin records and also noticed Resident #87 did not have a change in behavior. ASM #1 was not able to provide evidence that Resident #87 was assessed the day the allegation was reported.
When asked to provide evidence that a complete investigation was completed, ASM #1 stated an interview was conducted with Resident #37 and Resident #87's son. ASM #1 stated Resident #87 did have a skin assessment on 2/13/19 (the day prior to the allegation). ASM #1 was asked to provide any further details to evidence a complete and through investigation was conducted. ASM #1 provided a typed document dated 2/14 (no year) that documented, SW (Social Worker) notified (Resident #37) she is getting a new roommate. (Resident #37) stated, 'Why?' SW stated, 'your roommate's son has requested she be moved to another room' (Resident #37) stated, 'well does he know about (name of CNA)?' SW stated, 'What?' (Resident #37) stated, 'He got in the bed with her and raped her!' SW informed DON (Director of Nursing) and Administrator of what guest said. Administrator asked SW to investigate this more and get details from guest. SW went back to room and spoke with (Resident #37) about the situation. (Resident #37) stated, 'It was less than a month ago- I can't remember the day or time.' SW asked if guest knew if it was morning or night. (Resident #37) stated, 'Well it would have had to have been day because (name of CNA) works days.' (Resident #37) stated, 'The curtain was pulled so I could see half of (Resident #87). I saw (name of CNA) was lying in bed with her. He was on his left side facing her and I could see the back of his head. His head was not at the same level as her head. His head was at her titty. He was sucking on her titty.' (Resident #37) then stated, 'Then he fucked her.' SW asked guest if she actually saw this happen. (Resident #37) stated, 'Well, no, cause I could only see the half of them, but, the Lord Jesus told me he fucked her.' SW asked if guest said anything during all this. (Resident #37) stated, 'Well (Resident #87) has the dementia ya know.' SW stated she is aware that (Resident #87) has a dx (diagnosis) of dementia, but reiterated the question to (Resident #37), 'Did (Resident #87) say anything during this.' (Resident #37) stated, 'No, she just laid there.' (Resident #37) then stated, 'Well I told the other social worker about this.' SW stated, 'What other social worker?' (Resident #37) stated, 'The black one.' SW stated, '(Resident #37), we had a black social worker over a year ago, but not recently.' (Resident #37) stated, 'Well this was the night before last.' SW asked, 'What was the social worker's name? Did she identify herself as a social worker?' (Resident #37) stated, 'No, one of the aides told me.' SW stated, 'What aide?' (Resident #37) stated, 'Well one of the ones around was (name) .but I'm not sure she told me. One of the aides told me this person was a social worker but I'm not sure who.' SW asked, 'What was the social worker wearing?' (Resident #37) stated, 'She was wearing blue .the blue uniform. Wait, well that is what the aides wear!!!? Maybe they were lying to me!? But I told someone who I thought was a social worker.'
ASM #1 provided a statement signed by LPN (licensed practical nurse) #4 (unit manager) (no date) that documented, Writer spoke to Aide (name of accused CNA) regarding guest (room number) stating he was doing this to her roommate (room number). Aide and others interviewed, (name of accused CNA and name of another CNA) always went in room together because of (Resident #37's) statements. (Name of accused CNA) was taken out of that room for his safety and most of the aides go in (room number) in two's.
ASM #1 provided a statement signed by LPN #4 and dated 2/14/19 that documented, Son requested his mother be moved because of the nasty things (Resident #37) was saying to guest and family.
ASM #1 confirmed the allegation was not reported to the state agency or other officials because of the nature of the allegation and because the facility investigation was completed and the allegation was unfounded within the required time frame for reporting.
On 3/13/19 at 5:42 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern. ASM #1 was asked to provide any further information to evidence a complete and thorough investigation was completed.
On 3/14/19 at 11:46 a.m., a telephone interview was conducted with OSM (other staff member) #2 (the former social worker). OSM #2 stated she did not remember the details regarding Resident #37's allegation that Resident #87 was raped. OSM #2 stated she remembered that Resident #37 stated the CNA came in the room but she didn't actually see anything happen. OSM #2 stated Resident #37 said things like the CNAs head was at Resident #87's titty level. OSM #2 stated she asked Resident #37 if she saw the CNA touch Resident #87 and Resident #37 said she did not see the CNA do anything but what else would the CNA have been doing down there. OSM #2 stated she documented what she heard from Resident #37, gave the document to the administrator, called the psychiatrist and separated Resident #37 from her roommate (Resident #87).
The facility policy titled, ABUSE PROHIBITION, INVESTIGATION, AND REPORTING documented, It is the policy of this facility to prohibit mistreatment, neglect, and abuse of guests/residents and/or misappropriation of guest/ resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, or exploitation and all facility personnel with promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegations of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing, and/or certification board as required by State and Federal law .III. Investigation: A. The person(s) observing an incident of guest abuse or suspecting guest abuse must immediately report such incidents/suspicions to the Administrator. If the Administrator is not immediately available, the allegation should be reported to a charge nurse, social worker, or nursing administration to ensure that the guest is safe. The supervisor/management person in charge will then immediately notify the Administrator. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. The following information should be reported: 1. The name of the guest. 2. The date and time that the incident occurred. 3. The location of the incident. 4. The name(s) of the person(s) committing the incident, if known. 5. The name(s) of any witness (es) to the incident. 6. The type of abuse that was committed (e.g. verbal, physical, sexual, misappropriation, etc.). 7. Other information that may be requested. B. Upon receiving a report of abuse, the charge nurse will immediately examine the guest. If any injuries are identified, the charge nurse will notify the physician and administer treatment as ordered. The findings of the examination will be recorded in the medical record (The physician is to be notified timely even if no injuries are observed). C. Appropriate actions must be taken immediately to protect the guest and others who could be affected while the investigation is in progress. Accused individuals will be denied unsupervised access to the guest. If the allegation involves a family member of other visitor, visits may be made only in designated areas approved by the Administrator. Facility employees who have been accused of guest abuse will be suspended until the results of the investigation have been reviewed by the Administrator. D. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation and make the appropriate notifications as outlined on the form. E. The Administrator or designee will coordinate an immediate investigation in accordance with the investigation guidelines in this policy. The representative in charge of the investigation will consult with the Administrator daily concerning the progress of the investigation. A copy of the findings will be provided to the Administrator within five (5) working days of the occurrence of the incident. The investigation may consist of but is not limited to: 1. An interview with the person(s) reporting the incident. 2. Interviews with any witnesses to the incident. 3. An interview with the guest. 4. A review of the guest's medical record. 5. An interview with staff members (on all shifts) who had contact with the guest during the period of the alleged incident. 6. Interviews with the guest's roommate, family members, and visitors. 7. Physical assessment of other potentially affected guests. 8. A review of all circumstances surrounding the incident .IV. Initial Reporting: A. All allegations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property must be reported immediately to the Administrator .B. All phases of the reporting process will be kept confidential. C. The Administrator is responsible for ensuring that all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately reported to the State Agency and other officials in accordance with federal regulations and state guidelines. i. Allegations of abuse or serious bodily injury: If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the state immediately, but no later than two (2) hours after the allegation is made .IV. Final Reporting: A. The findings of the investigation must be submitted to the state agency within five (5) working days of the allegation .
No further information was presented prior to exit.
2. The facility staff failed to implement the abuse policy for reporting a resident-to-resident altercation when Resident # 89 received a scratch under their eye on 12/07/18. The incident was not reported to the State Agency until 12/10/18.
Resident # 89 was admitted to the facility on [DATE] and a readmission on [DATE] with diagnoses that included but were not limited to peripheral vascular disease (1), atherosclerosis (2) and hypertension (3).
Resident # 89's most recent comprehensive MDS (minimum [NAME] set) a significant change assessment with an ARD (assessment reference date) of 02/19/19 coded the resident as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 being cognitively intact for daily decision making. Resident # 89 was coded as requiring supervision and set up for activities of daily living and independent with eating.
The facility's Facility reported Incident (FRI) documented, Report Date: 12/10/18. Incident Date: 12/7/18. Residents involved: (Name of Resident # 2) and (Name of Resident # 89). Injuries: Yes. Scratch under eye of (Name of Resident # 89). Area cleaned. No treatment needed. Under the heading Describe incident, including location and action taken it documented, Nurse entered room to find both guests striking and yelling at each other. Striking was initiated by (Name of Resident # 2) who also slid out of WC (wheelchair) when he rolled into (Name of Resident # 89). (Name of Resident # 2) removed from room. Q (every) 15 minutes checks initiated on both guest. Further review of the facility's FRI revealed documentation that the responsible party and physician were notified on 12/7/18. Review of the facility's facsimile Send Result Report attached to the FRI documented, To: (Name of Person), Dept (department) of Health. (Name of Person), Ombudsman, (Name of Person), APS (Adult Protective Services). From: (Name of Nursing Home). Date: 12/10/18.
On 03/14/19 at 4:40 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked to describe the reporting procedure of a (facility reported incident) FRI to the Office of Licensure and Certification, ASM # 2 stated, It's reported within two hours of the incident and the complete investigation within five days of the incident. After review the facility's FRI with the incident date of 12/07/18 regarding Resident # 89, ASM # 2 was asked if the FRI was submitted to the state agency within the correct time frame. ASM # 2 stated, No. The staff failed to notify me or the administrator until the tenth (12/10/18). When asked to describe the procedure for reporting, ASM # 2 stated, It's the staff's responsibility to notify us, myself or the administrator immediately and if we are not in the building they are to notify the on-call manager immediately.
On 03/14/19 at approximately 5:00 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, ASM # 3, regional director of operations, and ASM # 4, regional clinical coordinator were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the fa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report allegations of abuse within the required time frame for two of 53 residents in the survey sample, Residents #87 and #89.
1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to report this allegation to the state agency and other agencies according to law.
2. The facility staff failed to ensure timely reporting to the State Agency and other officials in accordance with state law when Resident # 89 received a scratch under their eye on 12/07/18 during a resident to resident altercation. The incident was not reported until 12/10/18.
The findings include:
1. On 2/14/19 Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to report this allegation to the state agency and other agencies according to law.
Resident #37 was admitted to the facility on [DATE]. Resident #37's diagnoses included but were not limited to high blood pressure, major depressive disorder and delusional disorders. Resident #37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/30/19, coded the resident as being cognitively intact. Section G coded Resident #37 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene.
Resident #87 was admitted to the facility on [DATE]. Resident #87's diagnoses included but were not limited to diabetes, high blood pressure and a fractured right arm. Resident #87's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/28/19, coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #87 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene.
On 3/12/19 at 1:53 p.m., an interview was conducted with Resident #37. Resident #37 stated the facility CNAs (certified nursing assistants) were abusive. Resident #37 stated within the last couple of months, that a CNA was in bed with Resident #87 (former roommate). Resident #37 stated the CNA's head was at the level of Resident #87's titties. Resident #37 stated the CNA was raping Resident #87. When asked if she had reported this information to the facility staff, Resident #37 stated she reported this to the social worker, a nurse and a CNA.
On 3/12/19 at 2:08 p.m. (immediately after the interview with Resident #37), the above allegation was reported to ASM (administrative staff member) #1 (the administrator). ASM #1 stated he was aware of the allegation and would provide additional information. ASM #1 was asked to provide evidence that the state agency and other officials were notified regarding the allegation.
On 3/13/19 at 4:06 p.m., an interview was conducted with ASM #1. ASM #1 stated on 2/14/19 Resident #37 reported an allegation of rape to the former social worker after Resident #37 was told she was getting a new roommate. ASM #1 stated the social worker interviewed Resident #37 and Resident #37 stated she did not witness the rape but Jesus told her. ASM #1 stated the unit manager interviewed the CNA who allegedly raped Resident #87 and interviewed the resident's son who did not have any concerns. When asked if other staff was interviewed or if Resident #87 was assessed after Resident #37 voiced the allegation, ASM #1 stated Resident #37 stated the alleged rape occurred less than a month after that date but could not remember a date or time. ASM #1 confirmed the allegation was not reported to the state agency or other officials because of the nature of the allegation and because the facility investigation was completed and the allegation was unfounded within the required time frame for reporting.
On 3/13/19 at 5:42 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern. ASM #1 was asked to provide any further information to evidence a complete and thorough investigation was completed.
The facility policy titled, ABUSE PROHIBITION, INVESTIGATION, AND REPORTING documented, It is the policy of this facility to prohibit mistreatment, neglect, and abuse of guests/residents and/or misappropriation of guest/ resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, or exploitation and all facility personnel with promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegations of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing, and/or certification board as required by State and Federal law .IV. Initial Reporting: A. All allegations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property must be reported immediately to the Administrator .B. All phases of the reporting process will be kept confidential. C. The Administrator is responsible for ensuring that all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are immediately reported to the State Agency and other officials in accordance with federal regulations and state guidelines. i. Allegations of abuse or serious bodily injury: If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the state immediately, but no later than two (2) hours after the allegation is made .IV. Final Reporting: A. The findings of the investigation must be submitted to the state agency within five (5) working days of the allegation .
No further information was presented prior to exit.
2. The facility staff failed to ensure timely reporting to the State Agency and other officials in accordance with state law when Resident # 89 received a scratch under their eye on 12/07/18 during a resident to resident altercation. The incident was not reported until 12/10/18.
Resident # 89 was admitted to the facility on [DATE] and a readmission on [DATE] with diagnoses that included but were not limited to peripheral vascular disease (1), atherosclerosis (2) and hypertension (3).
Resident # 89's most recent comprehensive MDS (minimum [NAME] set) a significant change assessment with an ARD (assessment reference date) of 02/19/19 coded the resident as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 being cognitively intact for daily decision making. Resident # 89 was coded as requiring supervision and set up for activities of daily living and independent with eating.
The facility's Facility reported Incident (FRI) documented, Report Date: 12/10/18. Incident Date: 12/7/18. Residents involved: (Name of Resident # 2) and (Name of Resident # 89). Injuries: Yes. Scratch under eye of (Name of Resident # 89). Area cleaned. No treatment needed. Under the heading Describe incident, including location and action taken it documented, Nurse entered room to find both guests striking and yelling at each other. Striking was initiated by (Name of Resident # 2) who also slid out of WC (wheelchair) when he rolled into (Name of Resident # 89). (Name of Resident # 2) removed from room. Q (every) 15 minutes checks initiated on both guest. Further review of the facility's FRI revealed documentation that the responsible party and physician were notified on 12/7/18. Review of the facility's facsimile Send Result Report attached to the FRI documented, To: (Name of Person), Dept (department) of Health. (Name of Person), Ombudsman, (Name of Person), APS (Adult Protective Services). From: (Name of Nursing Home). Date: 12/10/18.
On 03/14/19 at 4:40 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked to describe the reporting procedure of a (facility reported incident) FRI to the Office of Licensure and Certification, ASM # 2 stated, It's reported within two hours of the incident and the complete investigation within five days of the incident. After review the facility's FRI with the incident date of 12/07/18 regarding Resident # 89, ASM # 2 was asked if the FRI was submitted to the state agency within the correct time frame. ASM # 2 stated, No. The staff failed to notify me or the administrator until the tenth (12/10/18). When asked to describe the procedure for reporting, ASM # 2 stated, It's the staff's responsibility to notify us, myself or the administrator immediately and if we are not in the building they are to notify the on-call manager immediately.
On 03/14/19 at approximately 5:00 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, ASM # 3, regional director of operations, and ASM # 4, regional clinical coordinator were made aware of the findings.
No further information was provided prior to exit.
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 resident interview, staff interview, facility document review and clinical record review, it was determined that the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to complete a thorough abuse investigation for one of 53 residents in the survey sample, Resident #87.
On 2/14/19, Resident #37 reported an allegation that an employee had raped Resident #87. The facility staff failed to conduct a complete and thorough investigation regarding this allegation.
The findings include:
Resident #37 was admitted to the facility on [DATE]. Resident #37's diagnoses included but were not limited to high blood pressure, major depressive disorder and delusional disorders. Resident #37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/30/19, coded the resident as being cognitively intact. Section G coded Resident #37 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene.
Resident #87 was admitted to the facility on [DATE]. Resident #87's diagnoses included but were not limited to diabetes, high blood pressure and a fractured right arm. Resident #87's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/28/19, coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #87 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene.
On 3/12/19 at 1:53 p.m., an interview was conducted with Resident #37. Resident #37 stated the facility CNAs (certified nursing assistants) were abusive. Resident #37 stated that within the last couple of months, a CNA was in bed with Resident #87 (former roommate). Resident #37 stated the CNA's head was at the level of Resident #87's titties. Resident #37 stated the CNA was raping Resident #87. When asked if she had reported this information to the facility staff, Resident #37 stated she reported this to the social worker, a nurse and a CNA.
On 3/12/19 at 2:08 p.m. (immediately after the interview with Resident #37), the above allegation was reported to ASM (administrative staff member) #1 (the administrator). ASM #1 stated he was aware of the allegation and would provide additional information.
On 3/13/19 at 4:06 p.m., an interview was conducted with ASM #1. ASM #1 stated Resident #37 reported an allegation of rape to the former social worker after Resident #37 was told she was getting a new roommate. ASM #1 stated the social worker interviewed Resident #37 and Resident #37 stated she did not witness the rape but Jesus told her. ASM #1 stated the unit manager interviewed the CNA who allegedly raped Resident #87 and interviewed the resident's son who did not have any concerns. When asked if other staff was interviewed or if Resident #87 was assessed after Resident #37 voiced the allegation, ASM #1 stated Resident #37 stated the alleged rape occurred less than a month after that date but could not remember a date or time. When asked about the facility process for investigating a rape allegation, ASM #1 stated in this case, Resident #37 reported the alleged rape did not occur that day so staff reviewed past skin records and also noticed Resident #87 did not have a change in behavior. ASM #1 was not able to provide evidence that Resident #87 was assessed the day the allegation was reported.
When asked to provide evidence that a complete investigation was completed, ASM #1 stated an interview was conducted with Resident #37 and Resident #87's son. ASM #1 stated Resident #87 did have a skin assessment on 2/13/19 (the day prior to the allegation). ASM #1 was asked to provide any further details to evidence a complete and through investigation was conducted. ASM #1 provided a typed document dated 2/14 (no year) that documented, SW (Social Worker) notified (Resident #37) she is getting a new roommate. (Resident #37) stated, 'Why?' SW stated, 'your roommate's son has requested she be moved to another room' (Resident #37) stated, 'well does he know about (name of CNA)?' SW stated, 'What?' (Resident #37) stated, 'He got in the bed with her and raped her!' SW informed DON (Director of Nursing) and Administrator of what guest said. Administrator asked SW to investigate this more and get details from guest. SW went back to room and spoke with (Resident #37) about the situation. (Resident #37) stated, 'It was less than a month ago- I can't remember the day or time.' SW asked if guest knew if it was morning or night. (Resident #37) stated, 'Well it would have had to have been day because (name of CNA) works days.' (Resident #37) stated, 'The curtain was pulled so I could see half of (Resident #87). I saw (name of CNA) was lying in bed with her. He was on his left side facing her and I could see the back of his head. His head was not at the same level as her head. His head was at her titty. He was sucking on her titty.' (Resident #37) then stated, 'Then he fucked her.' SW asked guest if she actually saw this happen. (Resident #37) stated, 'Well, no, cause I could only see the half of them, but, the Lord Jesus told me he fucked her.' SW asked if guest said anything during all this. (Resident #37) stated, 'Well (Resident #87) has the dementia ya know.' SW stated she is aware that (Resident #87) has a dx (diagnosis) of dementia, but reiterated the question to (Resident #37), 'Did (Resident #87) say anything during this.' (Resident #37) stated, 'No, she just laid there.' (Resident #37) then stated, 'Well I told the other social worker about this.' SW stated, 'What other social worker?' (Resident #37) stated, 'The black one.' SW stated, '(Resident #37), we had a black social worker over a year ago, but not recently.' (Resident #37) stated, 'Well this was the night before last.' SW asked, 'What was the social worker's name? Did she identify herself as a social worker?' (Resident #37) stated, 'No, one of the aides told me.' SW stated, 'What aide?' (Resident #37) stated, 'Well one of the ones around was (name) .but I'm not sure she told me. One of the aides told me this person was a social worker but I'm not sure who.' SW asked, 'What was the social worker wearing?' (Resident #37) stated, 'She was wearing blue .the blue uniform. Wait, well that is what the aides wear!!!? Maybe they were lying to me!? But I told someone who I thought was a social worker.'
ASM #1 provided a statement signed by LPN (licensed practical nurse) #4 (unit manager) (no date) that documented, Writer spoke to Aide (name of accused CNA) regarding guest (room number) stating he was doing this to her roommate (room number). Aide and others interviewed, (name of accused CNA and name of another CNA) always went in room together because of (Resident #37's) statements. (Name of accused CNA) was taken out of that room for his safety and most of the aides go in (room number) in two's. ASM #1 provided a statement signed by LPN #4 and dated 2/14/19 that documented, Son requested his mother be moved because of the nasty things (Resident #37) was saying to guest and family.
On 3/13/19 at 5:42 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern. ASM #1 was asked to provide any further information to evidence a complete and thorough investigation was completed.
On 3/14/19 at 11:46 a.m., a telephone interview was conducted with OSM (other staff member) #2 (the former social worker). OSM #2 stated she did not remember the details regarding Resident #37's allegation that Resident #87 was raped. OSM #2 stated she remembered that Resident #37 stated the CNA came in the room but she didn't actually see anything happen. OSM #2 stated Resident #37 said things like the CNAs head was at Resident #87's titty level. OSM #2 stated she asked Resident #37 if she saw the CNA touch Resident #87 and Resident #37 said she did not see the CNA do anything but what else would the CNA have been doing down there. OSM #2 stated she documented what she heard from Resident #37, gave the document to the administrator, called the psychiatrist and separated Resident #37 from her roommate (Resident #87).
The facility policy titled, ABUSE PROHIBITION, INVESTIGATION, AND REPORTING documented, It is the policy of this facility to prohibit mistreatment, neglect, and abuse of guests/residents and/or misappropriation of guest/ resident property or resources. The facility shall not allow verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, or exploitation and all facility personnel with promptly report any incident or suspected incident of guest mistreatment, injuries of unknown source or misappropriation of property/resources. Reports of alleged abuse and/or misappropriation will be immediately reported to the Administrator and thoroughly investigated. Allegations of abuse/misappropriation and the investigative conclusion will be reported to the appropriate State regulatory agency, Law Enforcement agency, licensing, and/or certification board as required by State and Federal law .III. Investigation: A. The person(s) observing an incident of guest abuse or suspecting guest abuse must immediately report such incidents/suspicions to the Administrator. If the Administrator is not immediately available, the allegation should be reported to a charge nurse, social worker, or nursing administration to ensure that the guest is safe. The supervisor/management person in charge will then immediately notify the Administrator. When an incident of guest abuse is alleged, the incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. The following information should be reported: 1. The name of the guest. 2. The date and time that the incident occurred. 3. The location of the incident. 4. The name(s) of the person(s) committing the incident, if known. 5. The name(s) of any witness (es) to the incident. 6. The type of abuse that was committed (e.g. verbal, physical, sexual, misappropriation, etc.). 7. Other information that may be requested. B. Upon receiving a report of abuse, the charge nurse will immediately examine the guest. If any injuries are identified, the charge nurse will notify the physician and administer treatment as ordered. The findings of the examination will be recorded in the medical record (The physician is to be notified timely even if no injuries are observed). C. Appropriate actions must be taken immediately to protect the guest and others who could be affected while the investigation is in progress. Accused individuals will be denied unsupervised access to the guest. If the allegation involves a family member of other visitor, visits may be made only in designated areas approved by the Administrator. Facility employees who have been accused of guest abuse will be suspended until the results of the investigation have been reviewed by the Administrator. D. The Administrator will appoint a representative to investigate the incident. The Administrator will initiate the Investigation of Alleged Abuse, Mistreatment, or Misappropriation and make the appropriate notifications as outlined on the form. E. The Administrator or designee will coordinate an immediate investigation in accordance with the investigation guidelines in this policy. The representative in charge of the investigation will consult with the Administrator daily concerning the progress of the investigation. A copy of the findings will be provided to the Administrator within five (5) working days of the occurrence of the incident. The investigation may consist of but is not limited to: 1. An interview with the person(s) reporting the incident. 2. Interviews with any witnesses to the incident. 3. An interview with the guest. 4. A review of the guest's medical record. 5. An interview with staff members (on all shifts) who had contact with the guest during the period of the alleged incident. 6. Interviews with the guest's roommate, family members, and visitors. 7. Physical assessment of other potentially affected guests. 8. A review of all circumstances surrounding the incident .
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence that all required information, including comprehensive care plan goals, was provided to the receiving hospital when one of 53 residents in the survey sample, Resident #20, was transferred to the hospital on [DATE] and 12/24/18.
The facility staff failed to provide the receiving hospital with the Resident #20's comprehensive care plan goals during a facility initiated transfer to the hospital on [DATE] and 12/24/18.
The findings include:
Resident #20 was admitted to the facility on [DATE] with a recent with diagnoses that included but were not limited to, heart failure, sleep apnea [a condition in which the patient has transient periods of apnea during sleep (1)], obesity, diabetes and depression.
The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/10/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of two or more staff members for her toileting needs.
The nurse's note dated, 12/17/18, at 2:31 p.m. documented, Resident lethargic and speech garbled. Friend called facility and stated he visited yesterday and 'thinks she should be sent to the ER [emergency room]. RP (responsible party) #1 called and notified of residents condition and agreed with sending her to the hospital. NP (nurse practitioner) over to see and gave order to send her to (Name of hospital) ER. VS (vital signs) 98.1 (temperature) 108 (heart rate) 20 (respirations) 125/85 (blood pressure) O2 (oxygen) sat (saturation level) 99% on Bipap [Bi - PAP, bi-level Positive Airway Pressure, is a machine used to assist people who are diagnosed with sleep apnea. Bi Pap machine can be set for breathing in and breathing out pressure settings (2)]. Resident sent to (name of hospital) ER for eval (evaluation) via 911 (emergency medical services). Report called to ER nurse. Transfer form, Bed hold policy and med (medication) list sent with EMTs (emergency medical technicians).
The nurse's note dated, 12/24/18 at 2:53 a.m. documented in part, Guess (sic) had a sudden change in respiratory breathing. Woke yelling for help. On entering room to observe (sic) Guess (sic) greatly heaving for breath and struggling to breath. Immediate called other nurses to room. Obtain VS (vital signs), hooked Guess (sic) to O2 (oxygen) tan with rebreather mask. O2 sats (saturations) had dropped into 70/80, with mask on and increase O2 to 4L (liters per minute). Sats rose to 98%, not maintaining. But Guess (sic) respiration not improved, labored and heavy struggling to breathe. Nurse called for emergency squad. Transporting Guesss (sic) to (initials of hospital) ER (emergency room). Report to on call MD (medical doctor) and called RR (resident representative).
Review of the Nursing Home to Hospital Transfer Form failed to evidence documentation that the care plan goals were sent to the hospital for the residents facility initiated transfers on 12/17/18, or on 12/24/18.
The eInteract Transfer Form dated, 12/17/18, and 12/24/18, failed to evidence documentation that the care plan goals were sent to the hospital with the resident on 12/17/19 or 12/24/19.
An interview was conducted with LPN (licensed practical nurse) #1, on 3/14/19 at 1:56 p.m., regarding what documents are provided to the hospital for a facility initiated transfer of a resident to the hospital. LPN #1 stated, The bed hold policy, MARS (medication administration record), eInteract form, change in condition papers, care plan, my note. When asked where what information was sent with the resident is documented, LPN #1 stated, We have to do a transfer note in the clinical record after we send the resident out.
Review of the clinical record failed to evidence a Transfer Note for 12/17/18 or 12/24/18.
An interview was conducted with RN (registered Nurse) #1, the assistant director of nursing, on 3/14/19 at 2:31 p.m. what information is sent with a resident for a facility initiated transfer to the hospital. RN #1 stated, We prepare the care plan goals, the face sheet, recent laboratory tests, recent x-ray results, we try to send the H&P (history and physical) or the last progress note from the MD (medical doctor). We send the copy of the MAR/TAR (medication administration record/treatment administration record), bed hold policy, transfer notice. When asked where it is documented that all of these documents went to the hospital, RN #1 stated, The nurse writes a transfer note documenting what documents were sent. The clinical record was reviewed with RN #1 for Resident #20's hospital transfer on 12/17/18 and 12/24/18. RN #1 stated she didn't see the note. RN #1 requested to go and look to see what she could find. She stated she thinks the nurses copy the papers sent to the hospital. RN #1 returned to this surveyor at 4:15 p.m. and stated she could not find any documentation of what information was sent to the hospital except what was documented above.
A request was made on 3/14/19 at approximately 5:30 p.m. for a copy of the policy for admissions, transfers and discharges.
Administrative staff member (ASM) #1, the administrator and ASM # 3, the regional director of operations, we made aware of the above concern on 3/14/19 at 4:33 p.m.
No further information was provided prior to exit.
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 534.
(2) This information was obtained from the following website: www.webmd.com/sleep-disorders/sleep-apnea.
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** 2. The facility staff failed to provide evidence that the Ombudsman was provided written notification of Resident #50's facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to provide evidence that the Ombudsman was provided written notification of Resident #50's facility initiated transfer to the hospital on 1/14/19.
Resident #50 was admitted to the facility on [DATE] with the diagnoses of but not limited to Adult Failure to Thrive, Pneumonia, Dysphagia, Type 2 Diabetes, high blood pressure, Stroke, hemiplegia and hemiparesis on right side, gastro-esophageal reflux disease. Resident #50's MDS (minimum data set) was an admission assessment with an Assessment Reference Date (ARD) of 1/17/19. Resident #50 was coded as moderately cognitively impaired in ability to make daily life decisions.
A review of the clinical record revealed a nurse's note on 1/14/19 at 4:28 PM, documented the following: Transfer form: document given to paramedics. Notification of transfer: was provided to MD (Medical Doctor), family: guardian, and paramedics. Bed hold policy: provided to paramedics. Medications: MAR provided to paramedics. Care Plan Goals: provided to paramedics.
A review of the clinical record revealed a nurse's note on dated 1/16/19 that documented, Late entry from 1/14/19: Guest sent out to ER (emergency room) for critical labs (laboratory test) results; guest left for (name of one hospital), but was diverted to (name of a second hospital). MD aware.
A review of the clinical record failed to reveal any evidence that the Ombudsman was provided with notification of the hospital transfer.
On 3/13/19 at 5:18 p.m., an interview with OSM # 3 (Other Staff Member) (Social Worker) was conducted. When asked if the Ombudsman is notified of a resident's facility initiated transfer, OSM #3 stated, We only send an end of the month report. I will need to go to someone else's office to get her book and will bring the January report to the conference room.
On 3/13/19 at 5:39 p.m., OSM #3 provided the January 2019, Ombudsman notification report, which did not reveal Resident #50's name. When asked if Resident #50 should be included in the report, OSM #3 stated, If they are going to the ER, we do not send a notification to the Ombudsman.
On 3/14/19 at approximately 3:15 p.m., the policy for Ombudsman notification for residents being transferred or discharged from the facility was requested.
On 3/14/19 at approximately 5:00 p.m., in a follow up interview with OSM # 3, regarding the policy for Ombudsman notification, she stated. There were no policies regarding hospital transfers and Ombudsman notification.
On 3/14/19 at approximately 3:30 p.m., ASM #1 (Administrative Staff Member) (Administrator) and ASM #3 (Regional Director of Operations) were made aware of the findings. No further information was provided by the end of the survey.
Based on staff interview and clinical record review, it was determined the facility staff failed to provide written notification to the resident and/or resident representative and/or ombudsman of a facility initiated transfer for two for 53 residents in the survey sample, Residents #20 and #50.
1. The facility staff failed to provide written notification to Resident #20 or the responsible representative for the 12/17/18 and 12/24/18 facility initiated transfers to the hospital.
2. The facility staff failed to provide evidence that the Ombudsman was provided written notification of Resident #50's facility initiated transfer to the hospital on 1/14/19.
The findings include:
1. The facility staff failed to provide written notification to Resident #20 or the responsible representative for the 12/17/18 and 12/24/18 facility initiated transfers to the hospital.
Resident #20 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, heart failure, sleep apnea [a condition in which the patient has transient periods of apnea during sleep (1)], obesity, diabetes and depression.
The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/10/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of two or more staff members for her toileting needs.
The nurse's note dated, 12/17/18 at 2:31 p.m. and 12/24/18 at 2:53 a.m., documented, Resident #20 was transferred to a local hospital on theses dates.
Review of the clinical record failed to evidence written notification of the transfers to the hospital on [DATE] and 12/24/18 was provided to Resident #20 and/or responsible representative.
An interview was conducted with LPN (licensed practical nurse) #1 on 3/14/19 at 1:56 p.m. When asked if written notification is provided to the resident or resident's responsible representative regarding why the resident was transferred to the hospital, LPN #1 stated, We call the family. I don't mail anything to anyone.
An interview was conducted with RN (registered nurse) #1 on 3/14/19 at 2:31 p.m. When asked if written notification is provided to the resident or resident's responsible representative regarding why the resident was transferred to the hospital, RN #1 stated, If the family member is in the building, we tell them. If they are not here in the building, we call them. RN #1 stated the transfer notice goes to the family, we provide a copy with the guest and it goes to the hospital. When asked for the location in the clinical record documenting this written notice being given to the resident and/or resident representative, RN #1 stated, I don't see it. It would be in a transfer note.
Review of the clinical record failed to evidence a Transfer Note for Resident #20's facility initiated hospital transfers on 12/17/18 and 12/24/18.
A request was made on 3/14/19 at approximately 5:30 p.m. for a copy of the policy for admissions, transfers and discharges.
Administrative staff member (ASM) #1, the administrator and ASM # 3, the regional director of operations, we made aware of the above concern on 3/14/19 at 4:33 p.m.
No further information was provided prior to exit.
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 534.
(2) This information was obtained from the following website: www.webmd.com/sleep-disorders/sleep-apnea.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to update a baseline care plan for one of 53 residents in the survey sample, Resident # 53.
The facility staff failed to update Resident # 53's baseline care plan concerning a fall on 02/11/19.
The findings include:
The facility staff failed to update Resident # 53's baseline care plan concerning a fall on 02/11/19.
Resident # 53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: muscle weakness, abnormalities of gait and mobility, cerebral infarction (1), aphasia (2), and hypertension (3).
Resident # 53s most recent comprehensive MDS (minimum [NAME] set) an admission assessment with an ARD (assessment reference date) of 02/15/19 coded the resident as scoring a 99 on the brief interview for mental status (BIMS) of a score of 0 - 15, 99 coded Resident # 53 as being unable to complete the brief interview for mental status. Under Staff Assessment for Mental Status Resident # 53 was coded a 2 (two), moderately impaired of cognition for daily decision making. Resident # 53 was coded as requiring extensive assistance of one staff member for activities of daily living and totally dependent of one staff member for eating. Under section J1900 Number of Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent coded Resident # 53 as having two or more falls with no injury.
The facility's Progress Notes dated 2/11/2019 for Resident # 53 documented, Nurse was called in room that guest has fallen out of his bed. Upon arrival, guest was lying face down and was returned to bed. Guest checked by the nurse and no injury noted, no cut, no knot noted. Neuro (neurological) checks initiated and are WNL (within normal limits). Guest was taken to the nurse's station and continue to propel self on the unit. VS (vital signs) = 96.2 (temperature), 65 (pulse), 16 (respiration), 134/67 (134 over 67 blood pressure), 99% (oxygen saturation). POA (power of attorney), MD (medical doctor) notified. Guest is up at the nurse's station at this time. Will monitor.
The facility's Incident Report dated 02/11/19 for Resident # 53 documented, Under Post Incident Analysis Additional explanation as apparent: Guest restless and continues to pull at PEG tube. MD/NP (medical doctor/nurse practitioner) to address and review meds (medications). Following this statement it documented, The above intervention has been incorporated into the guest's care plan and into the Nursing Care Instruction card and was signed by ASM (administrative staff member) # 2, the director of nursing with a date of 2/11/19.
The baseline care plan dated 2/8/19 for Resident # 53 was reviewed. Under Falls/Safety/Elopement Risks/Devices it documented, 2/8 (02/08/19). Evaluate for unsteady gait. 2/8. Orthostatic hypotension precautions. 2/8. Ambulation devices as necessary. 2/8. Instruct guest on appropriate safety measures. 2/8. Observe cognitive status for ability to ask for assistance. 2/8. Observe guest's footwear for fit and non-skid soles. Further review of the baseline care plan failed to evidence updates or reviews following Resident # 53's fall on 02/11/19.
On 03/14/19 at 10:13 a.m., an interview was conducted with RN (registered nurse) # 3, MDS coordinator. After reviewing the baseline care plan for Resident # 53 regarding the fall on 2/11/19, RN # 3 stated, It (baseline care plan) should have been updated with intervention of the MD/NP to assess and review the medications. It's not on the care plan. When asked to describe the procedure for updating a resident's baseline care plan, RN # 3 stated, When a resident falls the nurse is to implement an immediate intervention and it is communicated with management staff then IDT (interdisciplinary team) will meet to discuss falls and revise/update the care plan. When asked what policy they follow for updating the care plan, RN # 3 sated, We follow the RAI (resident assessment instrument) manual.
On 02/15/19 at approximately 5:00 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked if the recommendations or the Additional explanations on an the facility incident report were not documented on the baseline care plan, could you say that the baseline care plan was reviewed, revised or updated ASM # 2 stated, No.
On 03/14/19 at approximately 5:00 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, ASM # 3, regional director of operations, and ASM # 4, regional clinical coordinator were made aware of the findings.
No further information was provided prior to exit.
References:
(1) A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm .
(2) A disorder caused by damage to the parts of the brain that control language. It can make it hard for you to read, write, and say what you mean to say). This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/aphasia.html
(3) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to develop a comprehensive care plan to include and address Resident #50's risk for altered nutriti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to develop a comprehensive care plan to include and address Resident #50's risk for altered nutritional status based on the triggered Care Area Assessment (CAA) Summary - Nutritional Status from the Minimum Data Set (MDS) Section V dated 1/17/19.
Resident #50 was admitted to the facility on [DATE] with the diagnoses of but not limited to Adult Failure to Thrive, Pneumonia, Dysphagia, Type 2 Diabetes, high blood pressure, Stroke, hemiplegia and hemiparesis on right side, gastro-esophageal reflux disease. Resident #50's MDS was an admission assessment with an Assessment Reference Date (ARD) of 1/17/19. Resident #50 was coded as moderately cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for hygiene, dressing, toileting, transfers; setup and supervision for eating; and as always incontinent of bowel and bladder. Section V of the admission MDS documented Nutrition as a triggered care area. The MDS Section V trigger referred to the CAA Worksheet dated 1/24/19.
A review of the CAA Worksheet dated 1/24/19, signed by RN #3 (MDS Coordinator), documented the following as Resident #50's problem/need: Guest initially hospitalized d/t (due to) aspirational pneumonia and acute kidney injury, then discharged to SNF (Skilled Nursing Facility). While in hospital, guest was sent to hospital d/t abnormal labs (laboratory tests). Guest is chronically anemic, but required a blood transfusion. Guest requires supervision with eating and extensive assistance with all other ADLs (Activities of Daily Living). Under the Care Plan Considerations section: Will Nutritional Status - Functional Status be addressed in the care plan? RN #3 documented the following: Yes. If care planning for this problem, what is the overall objectives:? RN #3 documented the following: Improvement and minimize risks.
A review of the clinical record revealed the following weight log information for Resident #50. On 1/9/19, Resident #50's weight was recorded as 240.2 pounds. On 1/10/19, Resident #50's weight was recorded as 232.6 pounds using a mechanical lift. On 2/6/19, Resident #50's weight was recorded as 221.0 pounds using a mechanical lift. On 2/27/19, Resident #50's weight was recorded as 218.8 pounds.
A review of the clinical record revealed that on 1/9/19, the MD (Medical Doctor) ordered, Consistent carbohydrate diet, regular texture, thin consistency, and cardiac.
A review of the clinical record revealed that on 1/11/19, the MD documented the following: Review of Systems: Constitutional: Loss of appetite.
Further review of the clinical record revealed that on 2/5/19 at 3:00 p.m., the MD ordered, Sugar free health shake every day and evening shift for supplement.
A review of the clinical record revealed the following information on the MAR (Medication Administration Record) for February 2019; Resident #50 refused the day shift sugar free health shake 10 times with no refusals for the evening shift administration. The MAR for March 2019 documented that Resident #50 refused the day shift sugar free health shake eight times with one refusal for the evening shift administration.
A review of the ADLs (Activities of Daily Living) for January 2019 - March 2019, revealed that Resident #50 ate 0 - 25% of the breakfast meals - 26 times; the lunch meals - nine times; the dinner meals - zero times. A review of the ADLs for January 2019 - March 2019, revealed that Resident #50 ate 26 - 50% of the breakfast meals - 16 times; the lunch meals - seven times; the dinner meals - three times. The ADLs for January 2019 - March 2019, revealed that Resident #50 refused 14 meals.
Further review of the clinical record revealed that on 3/5/19 at 8:32 p.m., the physician progress notes documented Resident #50's weight patterns as above.
A review of the care plan for Resident #50 dated 1/22/19 revealed no documentation for being at risk for altered nutritional status or any interventions to address the resident's weight loss.
On 3/14/19 at 2:10 p.m., an interview with RN #6 (Unit Manager) was conducted. When asked if the MDS Section V triggers a CAA trigger for nutrition, should a resident centered care plan be initiated for that care area, RN #6 stated, Yes. When asked who is responsible for the initiation of a resident centered care plan, RN #6 stated, I would say the MDS Coordinator or the nurse. Any nurse should be able to do a care plan. RN #6 reviewed Resident #50's care plan. After the review, RN #6 was asked if Resident #50's care plan reflected an area addressing the CAA triggered area for nutrition. RN #6 stated, Cannot show it to you. The only thing I saw diet related is related to blood sugars but not nutrition. When asked if it should be care planned, when triggered on a CAA, RN #6 stated, I believe so, it should be. When asked if there was any issues with Resident #50's weight log, RN #6 stated, Weight loss. When asked if Resident #50's care plan reflected the weight loss or addressed the resident's nutrition, RN #6 stated, No.
On 3/14/19 at approximately 2:40 p.m., an interview with RN #3 (MDS Coordinator) was conducted. When asked if the MDS Section V triggers a CAA (care area assessment) trigger for nutrition, should a resident centered care plan be initiated for that care area, RN #3 stated, Yes. When asked who is responsible for the initiation of a resident centered care plan, RN #3 stated, The team, the IDT (Interdisciplinary team) team. The nutritional care plan is developed by the dietitian. RN #3 reviewed Resident #50's care plan. After the review, RN #3 was asked where the care plan reflected an area addressing the CAA triggered area for nutrition. RN #3 stated, I already audited it, if you go under the (the facility's electronic clinical record program), it is under the dehydration care plan. I updated it today (3/14/19) to include nutrition in the dehydration. When asked what prompted her to audit Resident #50's care plan. RN #3 stated that the facility identified Resident #50 as a resident that was being reviewed by the survey team and as a result of that, Resident #50 was identified as having not been care planned for nutrition and she added it to the dehydration care plan today (3/14/19). When asked if there was any issues with Resident #50's weight log, RN #3 stated, Yes. RN #3 was asked if Resident #50 should have had a care plan in place prior to today to address nutrition and the resident's weight loss. RN #3 stated, Yes.
On 3/14/19 at 3:10 p.m., an interview with OSM #12 (Other Staff Member) (Registered Dietitian) was conducted. OSM #12 was asked if the MDS Section V triggers a CAA trigger for nutrition, should a resident centered care plan be initiated for that care area. OSM #12 stated, With every resident, myself and my counterpart. Sounds like this resident (Resident #50) was not completed to the fullest. Every resident gets a care plan. I am always putting in a care plan for residents. That is best practices. That is typically, what we do. I don't know him (Resident #50) and I do not have (the facility's electronic clinical record program) in front of me. It is our practice to do a care plan, sounds like it was not completed and is an outlier and an issue. The assessment that was opened, (for Resident #50) and was not completed. I can assess him (Resident #50) in the morning. We do all components at the same time. Evaluations in (the facility's electronic clinical record program) and if it triggers a CAA, we do a care plan. If a resident has a weight loss or gain we do put it in the care plan and revise it.
According to the RAI manual dated October 2018 on page 4-1 documented, Chapter 4: Care Area Assessment (CAA) Process and Care Planning - Section 4.1: Background and Rationale revealed the following: .The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. On page 4-32, Section 4.10 - The Twenty Care Areas - 12. Nutritional Status revealed the following: The Nutritional Status CAA process reflects the need for an in-depth analysis of residents with impaired nutrition and those who are at nutritional risk .may also trigger based on loss of appetite with little or no accompanying weight loss and despite the absence of obvious, outward signs of impaired nutrition.
On 3/14/19 at approximately 3:30 p.m., ASM #1 (Administrative Staff Member) (Administrator) and ASM #3 (Regional Director of Operations) were made aware of the findings. No further information was provided by the end of the survey.
Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 53 residents in the survey sample, Residents #36, and #50.
1. The facility staff failed to develop a care plan to address Resident #36's urinary incontinence.
2. The facility staff failed to develop a comprehensive care plan to include Resident #50's risk for altered nutritional status based on the triggered Care Area Assessment (CAA) Summary - Nutritional Status from the Minimum Data Set (MDS) Section V dated 1/17/19.
The findings include:
1. The facility staff failed to develop a care plan to address Resident #36's urinary incontinence.
Resident #36 was admitted to the facility on [DATE]. Resident #36's diagnoses included but were not limited to diabetes, high blood pressure and difficulty swallowing. Resident #36's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/28/19, coded the resident's cognition as moderately impaired. Section H coded Resident #36 as occasionally incontinent of urine. Section V coded urinary incontinence as a triggered care area and documented urinary incontinence would be addressed in the care plan. Review of Resident #36's comprehensive care plan dated 1/24/18 failed to document information regarding urinary incontinence.
On 3/13/19 at 3:49 p.m., an interview was conducted with LPN (licensed practical nurse) #6 (MDS coordinator). LPN #6 confirmed there was no care plan to address Resident #36's urinary incontinence. When asked if there should be, LPN #6 stated, Yes. LPN #6 stated Resident #36 was coded as being occasionally incontinent of urine. LPN #6 stated urinary incontinence triggered in the care area assessment and section V of the MDS documented the area would be care planned. LPN #6 stated the MDS coordinators reference the CMS (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) manual when developing care plans based on triggered care areas.
On 3/13/19 at 5:42 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional director of operations) were made aware of the above concern.
The facility policy titled, CARE PLAN documented, The Care Plan must be written and submitted by the attending physician prior to admission. Guests will not be admitted to this facility without a written care plan. The care plan will include: 1. Diagnoses, symptoms, complaints, and complications indicating the need for admission. 2. Description of the functional level of the individual. 3. Objectives and goals. 4. All appropriate orders (medications, treatments, activities, restorative services, diet, etc.). 5. Plans for continuing care. 6. Plans for discharge. The care plan and a written report of each evaluation must be entered in the guest's medical record. The above data will be utilized in developing the guest's individual care plan.
The CMS RAI manual documented:
SECTION V: CARE AREA ASSESSMENT (CAA) SUMMARY
Intent: The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as triggered care areas, which form a critical link between the MDS and decisions about care planning.
There are 20 CAAs in Version 3.0 of the RAI, which includes the addition of Pain and Return to the Community Referral. These CAAs cover the majority of care areas known to be problematic for nursing home residents. The Care Area Assessment (CAA) process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas.
The interdisciplinary team (IDT) then identifies relevant assessment information regarding the resident's status. After obtaining input from the resident, the resident's family, significant other, guardian, or legally authorized representative, the IDT decides whether or not to develop a care plan for triggered care areas.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to review and revise Resident #55's care plan to include oxygen administration.
Resident #55 was a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to review and revise Resident #55's care plan to include oxygen administration.
Resident #55 was admitted to the facility on [DATE]. Diagnoses for Resident #55 included but were not limited to Depression, Heart Failure, and Anxiety. Resident #55's Minimum Data Set (quarterly assessment) with an Assessment Reference Date of 02/08/2019 coded Resident #55 with moderate cognitive impairment. In addition, the Minimum Data set (MDS) coded Resident #55 as requiring existence assistance of one staff member with activities of daily living and limited assistance of one staff member with eating.
On 03/12/2019, Resident #55's clinical record was reviewed. The review showed a physician order dated 02/06/2019 that documented, Oxygen at 2 liters per minute every shift for shortness of breath. Resident #55's care plan dated 9/22/17, had not been reviewed and revised to include administering oxygen for shortness of breath.
On 03/12/2019 at approximately 11:15 a.m., Resident #55 was observed in bed wearing a nasal cannula connected to an oxygen concentrator. The concentrator was turned on and the ball on the flow meter was observed between two and two and a half liters.
An interview was conducted on 03/13/2019 at approximately 1:35 p.m. with ASM (administrative staff member) #2 (the director of nursing). ASM #2 was asked who is responsible for implementing and updating the care plans. ASM #2 stated, MDS Coordinator and MDS Nurses are responsible for implementing and updating the resident care plans. ASM #2 stated that nurses and unit managers are supposed to update the care plans as well but main MDS staff does the updates. ASM #2 was made aware that Resident #55's care plan had not been reviewed and revised to include oxygen administration for shortness of breath.
An interview was conducted on 03/13/2019 at approximately 1:37 p.m. with RN (registered nurse) #3 (MDS coordinator). RN #3 was asked who is responsible for implementing and updating the care plan. RN #3 stated, MDS Coordinator and MDS Nurses implement the care plans and the interdisciplinary team updates them. RN #3 was made aware that Resident #55's care plan had not been reviewed and revised to include oxygen administration for shortness of breath. RN #3 immediately corrected the care plan after being made aware of the omission.
On 03/13/2019 at approximately 5:30 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional director of operations), (ASM) #2 (the director of nursing) were made aware of findings.
No further information was presented prior to exit.
Based on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for two of 53 residents in the survey sample, Resident # 53, and # 55.
1. The facility staff failed to update Resident # 53's comprehensive care plan concerning a fall on 02/15/19.
2. The facility staff failed to review and revise Resident #55's care plan to include oxygen administration.
The findings include:
1. The facility staff failed to update Resident # 53's comprehensive care plan concerning a fall on 02/15/19.
Resident # 53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: muscle weakness, abnormalities of gait and mobility, cerebral infarction (1), aphasia (2), and hypertension (3).
Resident # 53s most recent comprehensive MDS (minimum [NAME] set) an admission assessment with an ARD (assessment reference date) of 02/15/19 coded the resident as scoring a 99 on the brief interview for mental status (BIMS) of a score of 0 - 15, 99 coded Resident # 53 as being unable to complete the brief interview for mental status. Under Staff Assessment for Mental Status Resident # 53 was coded a 2 (two), moderately impaired of cognition for daily decision making. Resident # 53 was coded as requiring extensive assistance of one staff member for activities of daily living and totally dependent of one staff member for eating. Under section J1900 Number of Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent coded Resident # 53 as having two or more falls with no injury.
The facility's Progress Notes dated 2/15/2019 for Resident # 53 documented, Guest found on floor of guest room, no injury observed, guest asked what happened but speech garbled and nurse unable to make out what guest was saying, guest vs (vital signs) stable and guest RP (responsible party) and NP (nurse practitioner) notified of fall, neuro (neurological check) started and staff encouraged to check in on guest frequently to assist with needs and concerns, call light placed in reach and staff will continue to monitor.
The facility's Incident Report dated 02/15/19 for Resident # 53 documented, Under Post Incident Analysis Additional explanation as apparent: Guest to be toileted after peg tube feeding. Following this statement it documented, The above intervention has been incorporated into the guest's care plan and into the Nursing Care Instruction card and was signed by ASM (administrative staff member) # 2, the director of nursing with a date of 2/18/19.
The comprehensive care plan dated 2/8/19 for Resident # 53 was reviewed. Under Need it documented, (Resident # 53) actual falls and is at risk for falls related injury and future falls R/T (related to): Confusion, Deconditioning, Gait/balance problems unsteady, non-ambulatory, Incontinence bowel, Poor communication/comprehension, impulsiveness, psychotropic medication use, hemiplegia, restlessness/impulsive, observation of becoming increase restless in dark. Date initiated 02/13/2019. Created on 02/13/2019. Further review of the comprehensive care plan failed to evidence updates or reviews following Resident # 53's fall on 02/15/19.
On 03/14/19 at 10:13 a.m., an interview was conducted with RN (registered nurse) # 3, MDS coordinator. After reviewing the comprehensive care plan for Resident # 53 dated 02/13/19 regarding the fall on 2/15/19, RN # 3 stated, It (comprehensive care plan) should have been updated with intervention of being toileted after peg tube feeding. It's not on the care plan. When asked to describe the procedure for updating a resident's comprehensive care plan, RN # 3 stated, When a resident falls the nurse is to implement an immediate intervention and it is communicated with management staff then IDT (interdisciplinary team) will meet to discuss falls and revise/update the care plan. When asked what policy they follow for updating the care plan, RN # 3 sated, We follow the RAI (resident assessment instrument) manual.
The RAI (Resident Assessment Instrument) 3.0 User's Manual Version 1.16 dated October 2018 documented, 4.7 The RAI and Care Planning As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.
On 02/15/19 at approximately 5:00 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked if the recommendations or the Additional explanations documented on an incident report were not documented on the comprehensive care plan, could you say that it was reviewed, revised or updated ASM # 2 stated, No.
On 03/14/19 at approximately 5:00 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, ASM # 3, regional director of operations, and ASM # 4, regional clinical coordinator were made aware of the findings.
No further information was provided prior to exit.
References:
(1) A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm .
(2) A disorder caused by damage to the parts of the brain that control language. It can make it hard for you to read, write, and say what you mean to say). This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/aphasia.html
(3) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.
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, staff interview and clinical record review, it was determined that the facility staff failed to follow pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for two of 53 residents in the survey sample, Residents #315 and #265.
1. The facility staff failed to clarify Resident #315's physician order regarding instruction for the removal of a lidocaine patch.
2. The facility staff failed to ensure that the physicians order for Resident # 265's prednisone (1) was transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018.
The findings include:
1. Resident #315 was admitted to the facility on [DATE]. Resident #315's diagnoses included but were not limited to multiple rib fractures, dislocation of left shoulder and diabetes. Resident #315's 14 day Medicare MDS (minimum data set) assessment with an ARD (assessment reference date) of 8/8/18, coded the resident's cognition as moderately impaired. Section J coded Resident #315 as reporting occasional pain during the last five days. Review of Resident #315's clinical record revealed a physician's order with a start date of 8/2/18 that documented, Lidocaine Patch 5%. Apply to Left Shoulder, Left Ribs topically one time a day for Pain. Resident #315's August 2018 MAR (medication administration record) documented the same order.
Lidocaine patches are used to relieve the pain of post-herpetic neuralgia (PHN; the burning, stabbing pains, or aches that may last for months or years after a shingles infection). Lidocaine is in a class of medications called local anesthetics. It works by stopping nerves from sending pain signals.
Lidocaine comes as a patch to apply to the skin. It is applied only once a day as needed for pain. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use lidocaine patches exactly as directed.
Your doctor will tell you how many lidocaine patches you may use at one time and the length of time you may wear the patches. Never apply more than three patches at one time, and never wear patches for more than 12 hours per day. Using too many patches or leaving patches on for too long may cause serious side effects. (1)
On 3/14/19 at 9:31 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 was asked to explain the instructions for the use of a lidocaine patch. LPN #4 stated, They are usually, usually the order is to put on in the morning and remove in 12 hours. I haven't seen very many that have other instructions. We usually put on at 9 (9:00 a.m.) and take off at 9 (9:00 p.m.). LPN #4 was asked what should be done if a physician's order does not contain instructions to remove the patch. LPN #4 stated, You need to just clarify cause I don't think I have ever seen one put on and just leave. When asked how nurses should clarify the order, LPN #4 stated nurses should contact the nurse practitioner or the physician. LPN #4 was shown Resident #315's lidocaine patch order and LPN #4 confirmed the order should have been clarified to include instructions for the removal of the patch.
Resident #315's care plan dated 7/27/18 failed to document information regarding the clarification of a physician's order for a lidocaine patch.
On 3/14/19 at 11:25 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional director of operations) and ASM #4 (the regional clinical coordinator) were made aware of the above concern. ASM #4 stated that they followed their facility standards, which were stated to be [NAME].
On 3/14/19 at 5:32 p.m., OSM (other staff member) #13 (the medical records director) stated the facility did not have a policy or standard of practice regarding physician order clarification.
According to Lippincott Manual of Nursing Practice, Eighth Edition: by [NAME] & [NAME], pg. 87 read: Nursing Alert: Unusual dosages or unfamiliar drugs should always be confirmed with the health care provider and pharmacist before administration. On pg. 15, the following is documented in part, Inappropriate Orders: 2. Although you cannot automatically follow an order you think is unsafe, you cannot just ignore a medical order, either. b. Call the attending physician, discuss your concerns with him, obtain appropriate .orders. c. Notify all involved medical and nursing personnel d. Document clearly.
No further information was presented prior to exit.
(1) This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603026.html
2. The facility staff failed to ensure that the physicians order for Resident # 265's prednisone (1) was transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018.
Resident # 265 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: heart failure (2), dementia (3), benign prostatic hyperplasia (4) and pituitary tumor (5).
The most recent MDS (minimum data set), an admission assessment, with an ARD (assessment reference date) of 05/10/2018, coded the Resident # 265 as scoring a 3 (three) on the brief interview for mental status (BIMS) of a score of 0 (zero) - 15, 3 (three) being severely impaired of cognition for daily decision-making. Resident # 265 was coded as requiring limited assistance of one staff member for activities of daily living.
The physician's telephone orders dated 06/11/18, for Resident # 265 documented, Prednisone 5 mg (five milligram) now and Prednisone 5mg PO (by mouth) q (every) day.
The eMAR (electronic medication administration record) dated June 2018 for Resident # 265 documented, Prednisone Tablet 5 MG. Give 1 (one) tablet by mouth one time only for pain for 1 (one) Day. Start Date: 6/11/2018. Review of the eMAR revealed a check mark on June 11, 2018 at 1849 (6:49 p.m.). Further review of the eMAR dated June 2018 for Resident # 265 failed to evidence Resident # 265 receiving another dose of prednisone until June 18, 2018, a lapse of six days. On this date, the eMAR documented, Prednisone Tablet 5 MG. Give 1 (one) tablet by mouth one time a day for inflammation. Start Date: 6/18/2018.
Review of the facility's (Name of Medication Back up System) Inventory sheet revealed the presence of prednisone. The inventory sheet documented, Prednisone 10 MG Tablet.
On 03/14/19 at 4:00 p.m., an interview was conducted with RN (registered nurse) # 6, unit manager. When asked about the check marks and 'X''s on the Resident #265's eMAR, RN # 6 stated that the check marks indicated the medication was given and the 'X''s indicated it was not done. RN # 6 was asked to review Resident # 265's eMAR dated June 2018 and the physician's telephone orders dated 06/11/18. When asked if the physician's order was followed for the administration of prednisone, RN # 6 stated, The order was entered into the system for the prednisone to be given now but not for the administration every day. When asked if Resident # 265 had received the prednisone from June 12, 2018 through June 18, 2018, RN # 7 reviewed the eMAR dated June 2018 and stated no. When asked to describe the process that staff should follow to ensure a resident is receiving a physician ordered medication, RN # 6 stated, When they (nursing) receive the order from the doctor they enter it in the system and follow it. When asked who signed the telephone order for the prednisone, RN # 6 stated it was (RN # 7).
On 03/14/19 at 4:11 p.m., an interview was conducted with RN (registered nurse) # 7. After reviewing the eMAR and telephone order for Resident # 265's prednisone, RN # 7 stated she signed the order. When asked why Resident # 265 did not receive prednisone from June 12, 1019 through June 18, 2019 and why the physician's order was not followed, RN # 7 agreed Resident # 265 did not receive the medication and stated, I don't know what happened.
On the morning of 03/14/2019, during a brief interview conducted with by another surveyor, ASM #4 stated that they (the facility) followed their facility standards, which were stated to be [NAME].
On 03/14/19 at approximately 5:00 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, ASM # 3, regional director of operations, and ASM # 4, regional clinical coordinator were made aware of the findings.
According to Fundamentals of Nursing- [NAME], [NAME] and [NAME] 2007 page 169, After you receive a written medication order, transcribe it onto a working document approved by your health care facility .read the order carefully, concentrate on copying it correctly, check it when you're finished. Be sure to look for order duplications that could cause your patient to receive a medication in error Page 181 reads, Nurses carry a great deal of responsibility for making sure that patients get the right drugs at the right time, in the right dose and by the right routes .this includes accurate documentation and explanation .
No further information was provided prior to exit.
Complaint deficiency
References:
(1) Used alone or with other medications to treat the symptoms of low corticosteroid levels (lack of certain substances that are usually produced by the body and are needed for normal body functioning). Prednisone is also used to treat other conditions in patients with normal corticosteroid levels. These conditions include certain types of arthritis; severe allergic reactions; multiple sclerosis (a disease in which the nerves do not function properly); lupus (a disease in which the body attacks many of its own organs); and certain conditions that affect the lungs, skin, eyes, kidneys blood, thyroid, stomach, and intestines. Prednisone is also sometimes used to treat the symptoms of certain types of cancer. Prednisone is in a class of medications called corticosteroids. It works to treat patients with low levels of corticosteroids by replacing steroids that are normally produced naturally by the body. It works to treat other conditions by reducing swelling and redness and by changing the way the immune system works. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601102.html.
(2) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm.
(3) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.
(4) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html.
(5) The pituitary gland is involved in the production of several essential hormones. Tumors arising from the pituitary gland itself are called adenomas or carcinomas. Pituitary adenomas are benign, slow-growing masses that represent about 10% of primary brain tumors. Pituitary carcinoma is the rare malignant form of pituitary adenoma. It is diagnosed on ly when there is proven spread (metastases) inside or outside the nervous system. This information was obtained from the website: https://www.abta.org/tumor_types/pituitary-tumors/?gclid=EAIaIQobChMI3tb7sKCM4QIVFMDICh12OgmFEAAYAyAAEgLODfD_BwE.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, clinical record review and in the course of complaint investigation, it was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide the necessary services to maintain good grooming, and personal hygiene for one of 53 residents in the survey sample, Resident #315.
The facility staff failed to provide a shower and/or bath from 7/30/18 through 8/13/18, to Resident #315, who was coded as requiring extensive assistance of one with Activities of daily living.
The findings include:
Resident #315 was admitted to the facility on [DATE]. Resident #315's diagnoses included but were not limited to multiple rib fractures, dislocation of left shoulder and diabetes. Resident #315's 14 day Medicare MDS (minimum data set) assessment with an ARD (assessment reference date) of 8/8/18, coded the resident's cognition as moderately impaired. Section G coded Resident #315 as requiring extensive assistance of two or more staff with bed mobility/transfers and as requiring extensive assistance of one staff with locomotion, dressing, eating, toilet use and personal hygiene. Section G further coded bathing as activity itself did not occur or family and/or non-facility staff provided care 100% of the time.
Review of Resident #315's July 2018 and August 2018 ADL (activity of daily living), documentation revealed the resident did not receive a shower and/or bath between 7/30/18 and 8/13/18. Review of nurses' notes from 7/30/18 through 8/13/18 failed to reveal documentation regarding showers/baths. Resident #315's care plan dated 7/27/18 documented, Requires assistance with ADL's r/t (related to) multiple fractures, shoulder dislocation, generalized weakness . The care plan failed to document specific information regarding showers/baths.
On 3/13/19 at 3:23 p.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated showers are given to residents, twice a week by the shower aide. CNA #3 stated the CNA assigned to the resident must provide the shower if the shower aide cannot do so. When asked if showers are documented, CNA #3 stated showers are documented in the computer system. When asked what is meant if a shower is not documented, CNA #3 stated, It wasn't given.
On 3/14/19 at 8:15 a.m., an interview was conducted with CNA #1 (one of the facility shower aides). CNA #1 stated residents are given showers twice a week. When asked if she was able to complete all of the scheduled showers, CNA #1 stated she tries her best and the other CNAs help her if needed. CNA #1 was asked if she documents the showers, she provides. CNA #1 stated she does so in the computer system. When asked what is meant if showers are not documented in the computer system, CNA #1 stated, It shouldn't be that way because even if they don't get a shower they get a bed bath so it still has to be documented.
On 3/14/19 at 9:31 a.m., LPN (licensed practical nurse) #4 (unit manager) was made aware of the above concern and asked to provide evidence that Resident #315 received a shower or bath between 7/30/18 and 8/13/18.
On 3/14/19 at 1:27 p.m., another interview was conducted with LPN #4. LPN #4 stated Resident #315's scheduled shower days were Mondays and Thursdays. LPN #4 stated Resident #315 should have received a shower on 8/2/18. LPN #4 stated she spoke to the shower aide who was responsible for giving showers that day and the shower aide could not remember giving Resident #315 a shower on that day. LPN #4 stated Resident #315 should have received a shower on 8/6/18. LPN #4 stated she was not able to reach the shower aide responsible for giving showers on that day. LPN #4 stated Resident #315 should have received a shower on 8/9/18. LPN #4 stated she spoke to the shower aide who was responsible for giving showers on that day and the shower aide could not remember giving Resident #315 a shower on that day.
On 3/14/19 at 11:25 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional director of operations) and ASM #4 (the regional clinical coordinator) were made aware of the above concern.
The facility policy titled, SHOWER/BATH documented, Unless otherwise directed by the charge nurse, all guests will receive either a shower bath or whirlpool bath twice weekly. Additional bathing will be accommodated upon guest and/or family request.
No further information was presented prior to exit.
COMPLAINT DEFICIENCY
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. The facility staff failed to administer Resident # 265's was prednisone (1) as prescribed by the physician. Resident #265's p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to administer Resident # 265's was prednisone (1) as prescribed by the physician. Resident #265's prednisone was not transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018.
Resident # 265 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: heart failure (2), dementia (3), benign prostatic hyperplasia (4) and pituitary tumor (5).
The most recent MDS (minimum data set), an admission assessment, with an ARD (assessment reference date) of 05/10/2018, coded the Resident # 265 as scoring a 3 (three) on the brief interview for mental status (BIMS) of a score of 0 (zero) - 15, 3 (three) being severely impaired of cognition for daily decision-making. Resident # 265 was coded as requiring limited assistance of one staff member for activities of daily living.
The physician's telephone orders dated 06/11/18, for Resident # 265 documented, Prednisone 5 mg (five milligram) now and Prednisone 5mg PO (by mouth) q (every) day.
The eMAR (electronic medication administration record) dated June 2018 for Resident # 265 documented, Prednisone Tablet 5 MG. Give 1 (one) tablet by mouth one time only for pain for 1 (one) Day. Start Date: 6/11/2018. Review of the eMAR revealed a check mark on June 11, 2018 at 1849 (6:49 p.m.). Further review of the eMAR dated June 2018 for Resident # 265 failed to evidence Resident # 265 receiving another dose of prednisone until June 18, 2018, a lapse of six days. The eMAR documented, Prednisone Tablet 5 MG. Give 1 (one) tablet by mouth one time a day for inflammation. Start Date: 6/18/2018.
Review of the facility's (Name of Medication Back up System) Inventory sheet revealed the presence of prednisone. The inventory sheet documented, Prednisone 10 MG Tablet.
On 03/14/19 at 4:00 p.m., an interview was conducted with RN (registered nurse) # 6, unit manager. When asked about the check marks and 'X''s on the Resident #265's eMAR, RN # 6 stated that the check marks indicated the medication was given and the 'X''s indicated it was not done. RN # 6 was asked to review Resident # 265's eMAR dated June 2018 and the physician's telephone orders dated 06/11/18. When asked if the physician's order was followed for the administration of prednisone, RN # 6 stated, The order was entered into the system for the prednisone to be given now but not for the administration every day. When asked if Resident # 265 had received the prednisone from June 12, 2018 through June 18, 2018, RN # 7 reviewed the eMAR dated June 2018 and stated no. When asked to describe the process that staff should follow to ensure a resident is receiving a physician ordered medication, RN # 6 stated, When they (nursing) receive the order from the doctor they enter it in the system and follow it. When asked who signed the telephone order for the prednisone, RN # 6 stated it was (RN # 7).
On 03/14/19 at 4:11 p.m., an interview was conducted with RN (registered nurse) # 7. After reviewing the eMAR and telephone order for Resident # 265's prednisone RN # 7 stated she signed the order. When asked why Resident # 265 did not receive prednisone from June 12, 1019 through June 18, 2019 and why the physician's order was not followed, RN # 7 agreed Resident # 265 did not receive the medication and stated, I don't know what happened.
On the morning of 03/14/2019, during a brief interview conducted by another surveyor, ASM #4 stated that they (the facility) followed their facility standards, which were stated to be [NAME].
On 03/14/19 at approximately 5:00 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, ASM # 3, regional director of operations, and ASM # 4, regional clinical coordinator were made aware of the findings.
According to Fundamentals of Nursing- [NAME], [NAME] and [NAME] 2007, Page 181 reads, Nurses carry a great deal of responsibility for making sure that patients get the right drugs at the right time, in the right dose and by the right routes .this includes accurate documentation and explanation .
No further information was provided prior to exit.
Complaint deficiency
References:
(1) Used alone or with other medications to treat the symptoms of low corticosteroid levels (lack of certain substances that are usually produced by the body and are needed for normal body functioning). Prednisone is also used to treat other conditions in patients with normal corticosteroid levels. These conditions include certain types of arthritis; severe allergic reactions; multiple sclerosis (a disease in which the nerves do not function properly); lupus (a disease in which the body attacks many of its own organs); and certain conditions that affect the lungs, skin, eyes, kidneys blood, thyroid, stomach, and intestines. Prednisone is also sometimes used to treat the symptoms of certain types of cancer. Prednisone is in a class of medications called corticosteroids. It works to treat patients with low levels of corticosteroids by replacing steroids that are normally produced naturally by the body. It works to treat other conditions by reducing swelling and redness and by changing the way the immune system works. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601102.html.
(2) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm.
(3) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.
(4) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html.
(5) The pituitary gland is involved in the production of several essential hormones. Tumors arising from the pituitary gland itself are called adenomas or carcinomas. Pituitary adenomas are benign, slow-growing masses that represent about 10% of primary brain tumors. Pituitary carcinoma is the rare malignant form of pituitary adenoma. It is diagnosed on ly when there is proven spread (metastases) inside or outside the nervous system. This information was obtained from the website: https://www.abta.org/tumor_types/pituitary-tumors/?gclid=EAIaIQobChMI3tb7sKCM4QIVFMDICh12OgmFEAAYAyAAEgLODfD_BwE.
Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure two of 53 sampled residents, (Resident #92 and Resident #265), received treatment and care in accordance with professional standards of practice and the comprehensive care plan.
1. The facility staff failed to have blood work drawn according to the physician orders for Resident #92.
2. The facility staff failed to administer Resident # 265's was prednisone (1) as prescribed by the physician. Resident #265's prednisone was not transcribed to the MAR (medication administration record) accurately, resulting in Resident #265 not receiving the prescribed medication from June 12, 2018 through June 18, 2018.
The findings include:
1. Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: brain cancer, muscle weakness, diabetes, depression, and high blood pressure.
The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/20/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable or making daily cognitive decisions.
The physician order dated 1/25/19 documented, CBC* and CMP** weekly starting on 1/28/19.
*A complete blood count or CBC is a blood test that measures many different parts and features of your blood, including: Red blood cells, which carry oxygen from your lungs to the rest of your body.
White blood cells, which fight infection. There are five major types of white blood cells. A CBC test measures the total number of white cells in your blood. A test called a CBC with differential also measures the number of each type of these white blood cells. Platelets, which help your blood to clot and stop bleeding. Hemoglobin, a protein in red blood cells that carries oxygen from your lungs and to the rest of your body. Hematocrit, a measurement of how much of your blood is made up of red blood. (1).
** A Comprehensive Metabolic Panel (CMP) is used as a broad screening tool to evaluate organ function and check for conditions such as diabetes, liver disease, and kidney disease. The CMP may also be ordered to monitor known conditions, such as hypertension, and to monitor people taking specific medications for any kidney- or liver-related side effects. If a doctor is interested in following two or more individual CMP components, she may order the entire CMP because it offers more information. (2).
Review of the clinical record failed to evidence documentation of the above ordered laboratory tests for 2/18/19.
Review of the Diagnostic/Laboratory Administration Record failed to document the orders for the weekly physician ordered CBC and CMP.
Review of the nurse's notes failed to evidence documentation related to the above ordered laboratory tests.
The comprehensive care plan dated, 1/28/19 and revised on 2/7/19, documented in part, Focus: (Resident #92) is at risk for complications of chemotherapy/radiation r/t (related to) cancer - right temporal brain tumor. The Interventions documented in part, Obtains labs (laboratory tests) and diagnostics as ordered and report abnormal findings to the physician.
An interview was conducted with RN (registered nurse) #1, the assistant director of nursing, on 3/14/19 at 2:31 p.m. When asked about the process staff follows for obtaining a physician ordered laboratory tests, RN #1 stated the nurse puts the order in (name of computer program). It's to be scheduled for the night shift. The nurse confirms the order, does the lab (laboratory) requisition and then the lab company comes between 3:00 a.m. and 4:00 a.m. to draw the blood. When asked how the facility tracks that the ordered lab tests have been done, RN #1 stated the facility has the lab tracking form and the results get faxed to the facility and scanned into (name of computer program). The orders above were reviewed with RN #1. RN #1 was informed that the laboratory test results for 2/18/19 physician ordered lab test could not be located in the clinical record. RN #1 stated she would go look into it.
On 3/14/19 at 4:12 p.m., RN #1 stated she could not find the lab result or the lab requisition slip for the laboratory test ordered for 2/18/19.
An interview was conducted with administrative staff member (ASM) #5, the nurse practitioner, on 3/14/19 at 5:10 p.m. When asked if she had ordered the CBC and CMP, ASM #5 reviewed the clinical record and stated the order had come from someone outside of the facility. ASM #5 reviewed the scanned documents in the clinical record and stated, The order came on his discharge instructions from the hospital. The labs were ordered to follow up on his platelets and his liver function.
The CBC dated, 2/11/19, documented his platelet count as being 174, with the normal range being 130 - 400. The CBC dated, 2/25/19, documented his platelet count as being 105, being below the normal range of 130 - 400.
The CMP dated, 2/11/19, documented the following Liver Function Tests*** laboratory results:
SGPT - 60 - normal range is 7 - 52 U/L (units per liter)
SGOT - 20 - normal 13 - 39 U/L
Alkaline phosphatase - 72 normal 34 - 104 U/L
Total Bilirubin - 0.5 - normal 0.20 - 1.20 mg/dL (Milligram/grams per deciliter)
Total Protein - 4.5 - normal 6.0 - 8.3 g/dL
The CMP dated, 2/25/19, documented the following laboratory results:
SGPT [serum glutamic-pyruvic transaminase part of a liver panel] - 67, higher than previous, above normal range
SGOT [serum glutamic-oxaloacetic transaminase also part of liver panel]- 25 - higher than previous, but still in normal range
Alkaline phosphatase - 74 - higher but still in normal range
Total Bilirubin - 0.8 - higher but still in normal range
Total Protein - 4.6 - increased but still not in normal range
***Liver function tests measure certain proteins, enzymes, and substances, including:
o Albumin, a protein that the liver makes
o Total protein (TP)
o Enzymes that are found in the liver, including alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT)
o Bilirubin, a yellow substance that is part of bile. It is formed when your red blood cells break down. Too much bilirubin in the blood can cause jaundice. There is also a urine test for bilirubin. (3)
ASM #1, the administrator, and ASM #3, the regional director of operations, were made aware of the above findings on 3/14/19 at 4:33 p.m.
The facility policy, Medication Administration documented in part, Policy: All medications and treatments shall be initiated, administered and/or discontinued in accordance with written physician orders.
In Fundamentals of Nursing 6th edition, 2005; [NAME] A. [NAME] and [NAME] Perry; Mosby, Inc; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients.
No further information was obtained prior to exit.
(1) This information was obtained from the following website: https://medlineplus.gov/lab-tests/complete-blood-count-cbc/
(2) This information was obtained from the following website: 2. http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&query=CMP&x=9&y=21
(3) This information was obtained from the following website: https://medlineplus.gov/liverfunctiontests.html
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 resident interview, family interview, facility document review and clinical record review, it was determined the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, facility document review and clinical record review, it was determined the facility staff failed to provide treatment and services to maintain or restore bladder and bowel function for one of 53 residents in the survey sample, Resident #92.
The facility staff failed to implement a toileting plan to maintain or restore Resident #92's bladder and bowel function.
The findings include:
Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: brain cancer, muscle weakness, diabetes, depression, and high blood pressure.
The Nursing Comprehensive Evaluation dated, 1/24/19, documented in part, under Section F. Genitourinary that the resident was continent of both bowel and bladder.
The MDS (minimum data set) assessment, an admission/Medicare Five day assessment, with an assessment reference date of 1/31/19, coded the resident in Section H - Bladder and Bowel as being frequently incontinent of bowel and bladder (2 or more episodes of urinary or bowel incontinence, but at least one episode of continent voiding or bowel movement). The resident was not coded as being on a toileting program for bowel or bladder.
The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/20/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable or making daily in cognitive decisions. In Section H - Bladder and Bowel as being frequently incontinent of bowel and bladder (2 or more episodes of urinary or bowel incontinence, but at least one episode of continent voiding or bowel movement). The resident was not coded as being on a toileting program for bowel or bladder.
Upon entrance, a list of resident's with pressure ulcers was requested. On 3/12/19 at 11:04 a.m., administrative staff member (ASM) #2, the director of nursing, stated that Resident #92 did not have a pressure ulcer but moisture associated skin damage.
The comprehensive care plan dated, 1/28/19, documented in part, (Resident #92) is incontinent of bowel and bladder. The Interventions documented in part, Check q(every) 2 hr (hours) and prn (as needed) for incontinence. Wash, rinse and dry perineum, change clothing after incontinence care as needed. Provide incontinent care with moisture barrier as needed after incontinent episodes.
An interview was conducted with Resident #92 and his wife on 3/12/19 at 11:15 a.m. When asked if he was continent of bowel and bladder, the resident's wife stated that if the urinal is properly placed for him, he could use it. She further stated that she and his sons place it for him when he asks. The resident was asked if he could tell when he needs to urinate and have a bowel movement, Resident #92 stated, Most of the time. They informed the surveyor that he wears a brief at all times and no one has offered the bedpan or urinal since they've been here.
On 3/13/19 at 4:03 p.m., ASM #2, the director of nursing, informed this surveyor that she observed Resident #92's buttock yesterday. ASM #2 stated she felt she needed to look at it herself. She stated that the resident had an order for Medihoney as treatment that started on 3/11/19. She stated, I felt it was a stage 2 pressure injury on his right buttock, it was beefy red and the top layer of skin was gone. The sacral/coccyx was measured as 0.5 cm (centimeters) length by 0.5 cm in width. It was like a hole with a yellow base. With that I called the nurse practitioner as to when she last saw the areas and she stated she had seen them on 3/8/19 and again on 3/11/19 and they were not as described to her. ASM #2 stated that they felt it was no longer moisture associated skin damage but a pressure ulcer.
An interview was conducted with RN (registered nurse) #6, the unit manager, on 3/14/19 at 10:17 a.m. RN #6 was asked to review the Nursing Comprehensive Evaluation dated, 1/24/19. The MDS assessments above were reviewed also. When asked if the resident was on a toileting program, RN #6 stated, We can look at it. When asked why the resident should feel like he has to use a brief and sit in a wet/soiled brief, RN #6 stated, He shouldn't. I'll go look at it.
An interview was conducted with RN #1, the assistant director of nursing on 3/14/19 at 2:31 p.m. The Nursing Comprehensive Evaluation dated, 1/24/19, was reviewed with RN #1. The MDS assessments above were reviewed also. When asked why the resident is wearing briefs, RN #1 stated, He shouldn't be. When asked if he should be on a toileting program, RN #1 stated, Yes, even if it's only 50 % of the time, he should be.
An interview was conducted with RN #6 on 3/14/19 at 3:12 p.m. RN #6 stated she went to talk to the resident's wife but the resident was being sent out to the hospital. She spoke with the nurse who completed the Nursing Comprehensive Evaluation dated, 1/24/19 and the nurse stated it should not have been documented as continent that was an error. RN #6 stated, I asked the nurse and aides if the family or resident had asked for a urinal and they told me they have never asked. The CNAs (certified nursing assistants) who care for Resident #92 were interviewed by RN #6 and they informed her that the resident and/or his family has ever voiced the need to use the bathroom. She recalled a conversation with the wife to leave the brief open but even during the care plan conference recently she never voiced anything related to toileting.
The facility policy, Bowel & Bladder Continence Program documented in part, Purpose: Assisting a resident to maintain or restore bowel and bladder continence may promote the following: Dignity, Independence, participation in activities and social functions, confidence, improved skin integrity .Facility staff will provide information and education to the resident's family and/or legal representative on choices related to their continence care and services related to their continence. Procedure: 1. Review the Nursing Comprehensive Evaluations to determine if the resident is incontinent of bowel or bladder. 2. Compete the Bowel Evaluation and/or Urinary Incontinence History and Observations when any level of incontinence in bowel and/or bladder is identified on the Nursing Comprehensive Evaluation. 3. Initiated the Elimination Pattern for a minimum of 3 days to collect information on elimination pattern of the resident 6. Behavior modification programming may be initiated of resident who meet the following requirements: a. Bladder or Bowel Retraining Program: i. Able to communicate a need to eliminate, ii. Experience an urge to eliminate, iii. Physical ability to delay elimination until reaching toilet, iv. Willing and able to participate, independently, or with prompts. b. Prompted/Structured Toileting: i. Able to establish patterns and/or cues indicating time and need for toileting, ii Will and able to participated, independently or with prompts. 7. Discuss the findings with the resident, family and/or legal representative and determine interventions to be included in the plan of care. Determine the resident's willingness and ability to participate in interventions. 8. Determine the appropriate plan for a resident unable to participated in a continence program. Reasons for not participating include, but were not limited to: a. Unable to participate due to: i. Indwelling catheter required to treat an irreversible medical condition, ii. comatose, iii. Unable to tolerate placement of bedpan, commode or toilet .v. Inability to identify the urge to urinate or have a bowel movement.
ASM #1, the administrator, and ASM #3, the regional director of operations, were made aware of the above concern on 3/14/19 at 4:33 p.m.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on staff interview and facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage.
The facility staff failed t...
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Based on staff interview and facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage.
The facility staff failed to ensure eight consecutive hours of RN coverage for four days, 2/16/19, 3/2/19, 3/3/19 and 3/9/19.
The findings include:
Review of facility staffing coverage for 2/10/19-3/14/19, revealed the facility failed to staff a RN for eight consecutive hours on 2/16/19, 3/2/19, 3/3/19 and 3/9/19.
On 3/13/19 at approximately 8:17 a.m., an interview was conducted with OSM (other staff member) #8 (the staffing coordinator). OSM #8 was asked if she was aware that there was not eight consecutive hours of RN coverage on 2/16/19, 3/2/19, 3/3/19 and 3/9/19. OSM #8 stated that she was aware. OSM #8 was asked if she knew why it was important to have eight consecutive hours of RN coverage daily.
OSM #8 stated that eight consecutive hours of RN coverage is needed for supervision of licensed practical nurses, certified nurse aides and to assess residents as needed. OSM #8 stated that if an RN isn't on the schedule and she cannot find one, she would notify the director of nursing. OSM #8 was asked if she notified the director of nursing on the days where there was no RN coverage. OSM #8 stated, Yes.
On 3/13/19 at approximately 9:28 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 was asked if she was made aware that there was not eight consecutive hours of RN coverage on 2/16/19, 3/2/19, 3/3/19 and 3/9/19. ASM #2 stated she was aware and that she is working very hard to make sure the facility has daily RN coverage going forward. OSM #8 also stated that they are seeking to hire a weekend supervisor.
On 3/13/19 at approximately 10:40 a.m., ASM #1 (the administrator) stated that the facility does not have a policy for staffing and RN staffing. ASM #1 stated they go by what the regulations say.
No further information was given prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 53 residents in the survey sample, received the treatment and care in accordance with professional standards of practice and the comprehensive care plan for Resident #92.
The facility staff failed to obtain physician ordered laboratory tests for Resident #92.
The findings include:
Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: brain cancer, muscle weakness, diabetes, depression, and high blood pressure.
The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/20/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable or making daily cognitive decisions.
The physician order dated 1/25/19 documented, CBC* and CMP** weekly starting on 1/28/19.
*A complete blood count or CBC is a blood test that measures many different parts and features of your blood, including: Red blood cells, which carry oxygen from your lungs to the rest of your body.
White blood cells, which fight infection. There are five major types of white blood cells. A CBC test measures the total number of white cells in your blood. A test called a CBC with differential also measures the number of each type of these white blood cells. Platelets, which help your blood to clot and stop bleeding. Hemoglobin, a protein in red blood cells that carries oxygen from your lungs and to the rest of your body. Hematocrit, a measurement of how much of your blood is made up of red blood. (1).
** A Comprehensive Metabolic Panel (CMP) is used as a broad screening tool to evaluate organ function and check for conditions such as diabetes, liver disease, and kidney disease. The CMP may also be ordered to monitor known conditions, such as hypertension, and to monitor people taking specific medications for any kidney- or liver-related side effects. If a doctor is interested in following two or more individual CMP components, she may order the entire CMP because it offers more information. (2).
Review of the clinical record failed to evidence documentation of the above ordered laboratory tests for 2/18/19.
Review of the Diagnostic/Laboratory Administration Record failed to document the orders for the weekly physician ordered CBC and CMP.
Review of the nurse's notes failed to evidence documentation related to the above ordered laboratory tests.
The comprehensive care plan dated, 1/28/19 and revised on 2/7/19, documented in part, Focus: (Resident #92) is at risk for complications of chemotherapy/radiation r/t (related to) cancer - right temporal brain tumor. The Interventions documented in part, Obtains labs (laboratory tests) and diagnostics as ordered and report abnormal findings to the physician.
An interview was conducted with RN (registered nurse) #1, the assistant director of nursing, on 3/14/19 at 2:31 p.m. When asked about the process staff follows for obtaining a physician ordered laboratory tests, RN #1 stated the nurse puts the order in (name of computer program). It's to be scheduled for the night shift. The nurse confirms the order, does the lab (laboratory) requisition and then the lab company comes between 3:00 a.m. and 4:00 a.m. to draw the blood. When asked how the facility tracks that the ordered lab tests have been done, RN #1 stated the facility has the lab tracking form and the results get faxed to the facility and scanned into (name of computer program). The orders above were reviewed with RN #1. RN #1 was informed that the laboratory test results for 2/18/19 physician ordered lab test could not be located in the clinical record. RN #1 stated she would go look into it.
On 3/14/19 at 4:12 p.m., RN #1 stated she could not find the lab result or the lab requisition slip for the laboratory test ordered for 2/18/19.
An interview was conducted with administrative staff member (ASM) #5, the nurse practitioner, on 3/14/19 at 5:10 p.m. When asked if she had ordered the CBC and CMP, ASM #5 reviewed the clinical record and stated the order had come from someone outside of the facility. ASM #5 reviewed the scanned documents in the clinical record and stated, The order came on his discharge instructions from the hospital. The labs were ordered to follow up on his platelets and his liver function.
The CBC dated, 2/11/19, documented his platelet count as being 174, with the normal range being 130 - 400. The CBC dated, 2/25/19, documented his platelet count as being 105, being below the normal range of 130 - 400.
The CMP dated, 2/11/19, documented the following Liver Function Tests*** laboratory results:
SGPT - 60 - normal range is 7 - 52 U/L (units per liter)
SGOT - 20 - normal 13 - 39 U/L
Alkaline phosphatase - 72 normal 34 - 104 U/L
Total Bilirubin - 0.5 - normal 0.20 - 1.20 mg/dL (Milligram/grams per deciliter)
Total Protein - 4.5 - normal 6.0 - 8.3 g/dL
The CMP dated, 2/25/19, documented the following laboratory results:
SGPT [serum glutamic-pyruvic transaminase part of a liver panel] - 67, higher than previous, above normal range
SGOT [serum glutamic-oxaloacetic transaminase also part of liver panel]- 25 - higher than previous, but still in normal range
Alkaline phosphatase - 74 - higher but still in normal range
Total Bilirubin - 0.8 - higher but still in normal range
Total Protein - 4.6 - increased but still not in normal range
***Liver function tests measure certain proteins, enzymes, and substances, including:
o Albumin, a protein that the liver makes
o Total protein (TP)
o Enzymes that are found in the liver, including alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT)
o Bilirubin, a yellow substance that is part of bile. It is formed when your red blood cells break down. Too much bilirubin in the blood can cause jaundice. There is also a urine test for bilirubin. (3)
ASM #1, the administrator, and ASM #3, the regional director of operations, were made aware of the above findings on 3/14/19 at 4:33 p.m.
The facility policy, Medication Administration documented in part, Policy: All medications and treatments shall be initiated, administered and/or discontinued in accordance with written physician orders.
In Fundamentals of Nursing 6th edition, 2005; [NAME] A. [NAME] and [NAME] Perry; Mosby, Inc; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients.
No further information was obtained prior to exit.
(1) This information was obtained from the following website: https://medlineplus.gov/lab-tests/complete-blood-count-cbc/
(2) This information was obtained from the following website: 2. http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&query=CMP&x=9&y=21
(3) This information was obtained from the following website: https://medlineplus.gov/liverfunctiontests.html
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, resident interview, staff interview, facility document review and clinical record review, it was determine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement infection control practices for one of 53 residents in the survey sample, and in the kitchen, Residents #164.
The facility staff failed to ensure the implementation of contact isolation precautions for Resident #164.
The findings include:
Resident #164 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: amputation of right great toe, MRSA [MRSA stands for methicillin-resistant Staphylococcus aureus. It causes a staph infection [pronounced staff infection] that is resistant to several common antibiotics. (1)], high blood pressure, diabetes, heart failure and has a colostomy [a surgical creation of an opening in the abdominal wall to allow material to pass from the bowel through that opening (2)].
There was no completed MDS (minimum data set) assessment. The Nursing Comprehensive Evaluation dated, 3/7/19, documented the resident was alert and oriented to time, place and person. The resident was documented as needing one to two person assist with ambulation. Resident #164 was documented as having an active infection and currently on antibiotics.
A nurse's note dated, 3/7/19 at 2:40 p.m., documented in part the following: admitted to facility following amputation of left great toe, guest is a+o (alert and oriented time three) and has MRSA in wound of toe guest orientated (sic) to surroundings, introduced to staff and encouraged to call for assistance when needed, call light placed in reach and staff will continue to monitor.
The physician order dated, 3/8/19, documented, Contact precautions r/t (related to) MRSA, all services to be provided in room.
Observation was made of Resident #164 on 3/12/19 at 10:55 a.m. The isolation cart and signs were posted outside the resident's room. The resident was not in his room at the time of this observation.
At approximately 1:30 p.m., the resident was observed in his room, in his wheelchair, asleep.
An interview was conducted with RN (registered nurse) #2 on 3/12/19 at 3:34 p.m. When asked what needed to be worn when entering Resident #164's room, RN #1 stated, He's on contact isolation. You must wear gown and gloves. Anyone going in his room has to be gowned and gloved. When RN #1 was informed Resident #164 was not in his room for much of the day, RN #2 stated, He's allowed to come out of the room as long as the area (wound on the residents toe) is covered.
On 3/12/19 at 3:41 p.m., Resident #164's room was observed. A family member was observed in the room. The family member was observed lying across the resident's bed. She did not have any isolation gear on. At 3:56 p.m., the family member was observed walking around the room. At 3:59 p.m., the family member was observed again lying across the resident's bed, without isolation protective gear in place.
An interview was conducted with Resident #164 on 3/13/19 at 10:05 a.m. When asked if he was told anything about being in isolation and it's restrictions, Resident #164 stated he had not been told anything about being on isolation. The resident informed this surveyor, that it was his niece visiting yesterday. I asked if his niece was told anything about the isolation precautions, Resident #164 stated, No, but they talked to her later in the afternoon about it.
An interview was conducted with RN #1, the assistant director of nursing, on 3/13/19 at 3:09 p.m. When asked if staff explain isolation precautions to residents with precautions in place, RN #1 stated, I would hope so. The nurse practitioner has long conversations with them. When asked if family members of residents on isolation precautions are instructed on what to do regarding the precautions, RN #1 stated, It should be done but it's not done every time. The family should be educated.
The comprehensive care plan dated, 3/13/19, documented in part, Focus: (Resident #164) at risk for s/sx (signs and symptoms) of acute infection r/t (related to) has MRSA - colonization. The Interventions documented in part, Contact Isolation: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag lines and close bag tightly before taking to laundry. Educate guest and family regarding the importance of following contact precautions. Educate guest and family regarding the importance of hand washing. Use antibacterial soap and disposable towels. Instruct visitors to wear disposable gloves and gown when in resident's room and to wash hands before leaving room.
The facility policy, Transmission - Based Precautions Contact Precautions documented in part, Policy: Contact Precautions will be used (in addition to Standard Precautions) for specified guest known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact or indirect contact .Gloves and Hand Washing: 1. Wear gloves when entering the room. 2. Change gloves during the course of provided care, after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). 3. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. Gowns: 1. Wear a gown (clean, non-sterile is adequate) when entering the room if you anticipate that your clothing will have substantial contact: a. with the guest, b. with environmental surfaces or items in the guest room .d. with wound drainage not contained by a dressing. 2. Remove the gown before leaving the guest's environment and discard in appropriate container. Ensure that clothing does not contact potentially contaminated environmental surfaces after gown removal .Visitors: 1. Place a sign on the door of the guest's room and instruct visitors to report to the Nurses' Station prior to entering.
Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were made aware of the above concern on 3/13/19 at 5:28 p.m.
No further information was provided prior to exit.
(1) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=MRSA&_ga=2.154406129.832194397.1552912848-938173006.1468851256.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 133.
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** 4. The facility staff failed to ensure light covers in multiple resident rooms were maintained in a clean and comfortable homeli...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to ensure light covers in multiple resident rooms were maintained in a clean and comfortable homelike manner. Gray residue and/or dust dirt was observed on top of the light covers in multiple resident rooms.
On 03/12/2019 at approximately 11:15 a.m., observations of the light covers in resident rooms were conducted. Gray residue and/or dust dirt was observed on top of the light covers in rooms #100, #101, #102, #103, #104, #105, #106, #109, #200, #202, #203, #204, #205, #206, #207, #208, #209, #210, #211, #300, #301, #302, #303, #304, #305, #306, #307, #308, #400, #402, #403, #404, #405, #406, #407, #408, #409, #500, #501, #502, #503, #504, #505, #506, #507, #508, #509, #510, #600, #601, #602, #603, #604, #605, #606, #607, #608, #609, #610, #701, #702, #703, #704, #705, #706, #707, #708, #709, #710, #711, #712 and #713. The gray residue could be removed with the swipe of a finger.
On 03/13/2019 at approximately 8:33 a.m., an interview was conducted with OSM (other staff member) #1 (housekeeping director). OSM #1 was asked about the process staff follows for cleaning and dusting a resident's room. OSM #1 stated that housekeepers high dust resident rooms from ceiling to floor, and then proceed to disinfect and wipe off all furniture and equipment in room after resident has transferred out of the room. OSM #1 stated that this is usually a twelve minute procedure. OSM #1 was asked how he ensures the resident rooms are cleaned. OSM #1 stated, Myself or another housekeeper would check resident rooms to ensure cleanliness. We also are made aware of housekeeping issues in morning meeting from the mock survey rounds. OSM #1 was asked if he made rounds to ensure resident rooms were cleaned. OSM #1 stated that due to a lack of staff, he was assisting in maintenance and had not been able to check rooms. OSM #1 was made of the above observations of the light covers in multiple resident rooms in need of cleaning.
On 03/14/2019 at approximately 11:25 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional director of operations) and ASM #4 (the regional clinical coordinator) were made aware of the above concern.
The facility policy titled, Daily Cleaning of Guest Rooms documented, Proper sequence of cleaning: Clean guest room first then proceed to rest room. Use separate cleaning cloth for each area to be cleaned. Clean room in a clock wise direction - high dusting, then clean the following, TV, night stand, window sills, glass items, picture frames, over bed tables, and etc. Move from the cleanest to the dirtiest items as you clean.
No further information was presented prior to exit.
3. The facility staff failed to maintain the heating/air conditioning units in rooms #103, #104, #105, #108, #109, #200, #202, #203, #204, #206, #209, #301, #302, #307, #401, #402, #501, #601, #606 and #705 in a clean and comfortable manner.
On 3/14/19 at 10:00 a.m., observations of the heating/air conditioning units in resident rooms were conducted. Black residue and/or dust/dirt was observed in the heating/air conditioning unit vents in rooms #103, #104, #105, #108, #109, #200, #202, #203, #204, #206, #209, #301, #302, #307, #401, #402, #501, #601, #606 and #705. The black residue and/or dust/dirt could be removed with the swipe of a finger.
Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to right lower leg fracture, muscle weakness and high blood pressure. Resident #8's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/31/18, coded the resident as being cognitively intact. Resident #8 resided in one of the above rooms. During the above observation, Resident #8 was made aware this surveyor was going to check her heating/air conditioning unit. Resident #8 stated, It needs to be cleaned badly.
On 3/14/19 at 10:39 a.m., an interview was conducted with OSM (other staff member) #1 (the housekeeping director). OSM #1 was asked about the facility process for cleaning the vents in the heating/air conditioning units. OSM #1 stated it was difficult to spray and wipe the vents in the units but a deep cleaning is conducted once a month and the housekeeping and maintenance staff removes the units and power washes them outside. OSM #1 stated there had been a little bit of a struggle because the maintenance department was down one employee. At this time, OSM #1 was taken to room [ROOM NUMBER] and shown the vent in the heating/air conditioning unit. OSM #1 confirmed the unit needed to be cleaned. OSM #1 was made aware of the observations above of the heating/air conditioning units in multiple rooms in need of cleaning.
On 3/14/19 at 11:25 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional director of operations) and ASM #4 (the regional clinical coordinator) were made aware of the above concern.
The facility policy titled, Daily Cleaning of Guest Rooms failed to document specific information regarding the cleaning of heating/air conditioning units.
No further information was presented prior to exit.
COMPLAINT DEFICIENCY
Based on observation, resident interview, staff interview, family interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to maintain and clean, comfortable, homelike environment for two of 53 residents in the survey sample, Residents #20 and #92 and for 74 of 78 resident rooms.
1. The facility staff failed to clean and store a bedpan in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall in Resident #20's bathroom.
2. The facility staff failed to maintain Resident #92's bathroom in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall.
3. The facility staff failed to maintain the heating/air conditioning units in rooms #103, #104, #105, #108, #109, #200, #202, #203, #204, #206, #209, #301, #302, #307, #401, #402, #501, #601, #606 and #705 in a clean and comfortable manner.
4. The facility staff failed to ensure light covers in multiple resident rooms were maintained in a clean and comfortable homelike manner. Gray residue and/or dust dirt was observed on top of the light covers in multiple resident rooms.
The findings include:
1. The facility staff failed to clean and store a bedpan in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall in Resident #20's bathroom.
Resident #20 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, heart failure, sleep apnea (a condition in which the patient has transient periods of apnea during sleep) (1), obesity, diabetes and depression.
The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/10/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of two or more staff members for her toileting needs.
Observation was made of Resident #20's bathroom on 3/12/19 at 4:26 p.m. A blue bedpan was observed on the floor, not in a bag, with three dark brown pieces of what appeared to be stool in it. There was a hole approximately two inches by two inches in the cove base at the bottom of the wall facing the door. When asked how long the bedpan had been on the floor, Resident #20 and her roommate both stated, A long time. The roommate stated she uses the bathroom.
Observation was made of Resident #20's bathroom on 3/13/19 at 9:26 a.m. A blue bedpan was observed on the floor, not in a bag, with three dark brown pieces of what appeared to be stool in it. There was a hole approximately two inches by two inches in the cove base at the bottom of the wall facing the door.
Observation was made of Resident #20's bathroom again on 3/14/19 at 8:15 a.m. The bedpan remained in the same place. The hole remained on the bottom of the wall.
Observation was made of Resident #20's bathroom on 3/14/19 at 8:32 a.m. with OSM (other staff member) # 1, the director of housekeeping. The bedpan had been removed from the bathroom. Resident #20 stated the CNA (certified nursing assistant) # 5 had just removed it from the bathroom. OSM #1 was asked if his staff should do anything with the dirty bedpan on the floor, OSM #1 stated his staff does not do anything with the bedpan but it's a team around here and they should have said something to the nursing staff about it. The hole in the wall was observed. OSM #1 stated it shouldn't be there and he was going to tell the maintenance director.
An interview was conducted with CNA #5 on 3/14/19 at 8:40 a.m. When asked what she removed from Resident #20's bathroom, CNA #5 stated she removed a bedpan and a female urinal. When asked if there was anything in the bedpan, CNA #5 stated, Yes, there was a couple drops of feces in it. CNA #5 was asked to explain the process for cleaning and storing of bedpans, CNA #5 stated, I would first rinse the bedpan with the sprayer that's in the bathroom. Then after it's clean, I put it in a clean trash bag and tie it to the handrail in the bathroom. When asked if the bedpan she removed from the bathroom was stored properly, CNA #5 stated, No, Ma'am. If you see it you should remove it.
An interview was conducted with RN (registered nurse) #5 on 3/14/19 at 8:49 a.m. When asked how are bedpans to be stored when not in use, RN #5 stated they should be cleaned and put in a plastic bag. When asked if a bedpan should be stored unbagged with feces in the bedpan on the floor of a resident's bathroom, RN #5 stated, 'No, anyone making rounds should do something about it if they see it.
The facility policy, Bedpans documented in part, 17. Dispose of urine and/or stool in the commode. 18. Remove and clean equipment and place soiled items in appropriate receptacles. Note: The bedpan should be clean and dry before storing.
Administrative staff member (ASM) #1, the administrator and ASM # 3, the regional director of operations, we made aware of the above concern on 3/14/19 at 4:33 p.m.
No further information was provided prior to exit.
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 534.
2. The facility staff failed to maintain Resident #92's bathroom in a sanitary manner and failed to repair a hole in the cove base at the bottom of the wall.
Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: brain cancer, muscle weakness, diabetes, depression, and high blood pressure.
The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 2/20/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable or making daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for his toileting needs.
An interview was conducted with Resident #92 and his wife on 3/12/19 at 11:21 a.m. When asked if the facility keeps his room clean, Resident #92's wife stated the room is clean but the bathroom is not. Observation was made of the bathroom in Resident #92's room. A brown substance that appeared to be feces was observed on the sprayer hose next to the toilet. There was a brown debris where the wall and floor meet behind the toilet. There was a brown substance around the base of the toilet. A hole was observed, approximately two inches by two inches in the cove base at the base of the wall opposite the door.
The bathroom was again observed on 3/12/19 at 3:43 p.m., and 3/13/19 at 8:49 a.m. and again on 3/14/19 at 8:15 a.m. the observations above remained unchanged.
An interview was conducted with other staff member (OSM) #1, the housekeeping director, and OSM #10, the director of maintenance, on 3/14/19 at 8:22 a.m. When shown Resident #92's bathroom, and asked if the hole should be in the wall, OSM #10 stated, No, it should be repaired. The brown substance around the base of the toilet was shown to both staff. When asked what the brown substance was, OSM #10 stated, The toilet needs to resealed. The brown substance, that appeared to be feces, was shown to OSM #1, OSM #1 stated, That shouldn't be there, that needs to be cleaned. When asked about the black debris and brown around the base of the toilet, OSM #1 stated, This all needs to be cleaned.
An interview was conducted with administrative staff member (ASM) #3, the regional director of operations, on 3/14/19 at 11:07 a.m. When asked how often the bathrooms in resident's rooms are cleaned, ASM #3 stated, If the room is occupied, then it should be cleaned daily.
An interview was conducted with CNA (certified nursing assistant) #4 on 3/14/19 at 11:10 a.m. When asked how and to who, staff communicate broken items in need of repair in a resident's room, CNA #4 state, I walk around to the maintenance department or I tell the secretary to call them.
An interview was conducted with OSM #10, the director of maintenance, on 3/14/19 at 1:52 p.m. When asked how he is informed of things that need to be fixed, OSM #10 stated, The computer system - Tels. When asked who has access to it, OSM #10 stated all of the staff has access to it.
An interview was conducted with OSM #9, the unit secretary, on 3/14/19 at 2:08 p.m. When asked what Tels was, OSM #9 stated she would find out and get back with me. At 3:02 p.m., OSM #9 returned to this surveyor and stated it is a work order system for maintenance and housekeeping. When asked if she uses it, OSM #9 stated, No, It's quicker for me to just call them.
An interview was conducted with ASM #1, the administrator, on 3/14/19 at 2:27 p.m. When asked how the staff tell maintenance about something that is broken, ASM #1 stated, We have an electronic work order system that everyone has access to. Every computer has an icon for it.
The facility policy, Daily Cleaning of Guest Rooms documented in part, Policy: The daily cleaning and disinfecting of guest rooms will maintain the health of our guest and reduce the spread of infection throughout the facility. 4. Proper sequence of cleaning: clean [NAME] room first then proceed to rest room. Use separate cleaning cloth for each area to be cleaned. Clean room in a clock wise direction - high dusting, then clean the following, TV, night stand, window sills, glass items, picture frames, over bed tables, and etc. Move from the cleanest to the dirtiest items as you clean. 13. Report any items that need repaired to the maintenance department.
A request was made for the policy on maintenance repairs. On 3/14/19 at 5:32 p.m. OSM #13, the medical records director, informed the survey team the facility had no policy on maintenance repairs.
Administrative staff member (ASM) #1, the administrator and ASM # 3, the regional director of operations, we made aware of the above concern on 3/14/19 at 4:33 p.m.
No further information was obtained prior to exit.
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** 2. The facility staff failed to administer Resident #104's oxygen according to physician's orders.
Resident #104 was admitted to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to administer Resident #104's oxygen according to physician's orders.
Resident #104 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anemia (1) heart disease (2), hypertension (3), and idiopathic sleep related non-obstructive alveolar hypoventilation (4).
Resident #104's most recent MDS (minimum data set), an admission assessment with an ARD (Assessment Reference Date) of 02/26/19, coded Resident #104 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 104 was coded as requiring limited assistance of one staff member for activities of daily living, requiring supervision with set up for eating and as being totally dependent of one staff member for bathing.
On 03/12/2019 at approximately 11:46 a.m., an observation of Resident # 104's room revealed she was resting in her bed watching television. Further observation revealed Resident # 104 was receiving oxygen by nasal cannula connected to an oxygen concentrator. An observation of the oxygen concentrator's flow meter revealed the oxygen flow rate was between two and two-and-a-half liters per minute.
On 03/13/19 at approximately 08:05 a.m., an observation of Resident #104's room revealed Resident #104 was resting in her bed watching television. Further observation revealed Resident # 104 was receiving oxygen by nasal cannula connected to an oxygen concentrator. An observation of the oxygen concentrator flow meter revealed the oxygen flow rate was between two and two-and-a-half liters per minute.
The POS (physician's order sheet) dated March 2019 for Resident #104 documented, Oxygen at 2 l/m (two liter per minute) via (by) nasal cannula every shift for low sats (saturation). Order Date: 2/19/2019.
On 03/13/19 at approximately 4:45 p.m., an interview was conducted with RN #1 (registered nurse) #1. When asked how to read the oxygen flowrate on the oxygen concentrator, RN #1 stated, You get down to eye level and read the oxygen flow rate from the oxygen concentrator. RN #1 stated, The ball has to be centered on the line indicated on the oxygen concentrator flow meter. When asked why it is important to set the oxygen flowrate correctly for the resident, RN #1 stated, So the resident receives the correct level they are supposed to be getting. When asked what happens if a resident receive too much oxygen RN #1 stated, A resident with COPD (chronic obstructed pulmonary disease) (5) can suffer over inflation of their lungs. When asked what the physician's orders documented for Resident #104, RN #1 looked at the electronic clinical record and stated, O2 at two liter per minute, every shift for low O2 saturation. When asked how often the oxygen flow rate is checked on the oxygen concentrator for Resident #104, RN #1 stated, The flow rate on Resident #104's oxygen concentrator is checked every shift. When asked why Resident 104's oxygen flow rate was set between two and two and a half liters a minute instead of the physician 2 liters a minute, RN #1 stated, I will check the oxygen setting on Resident #104 and make the necessary adjustment.
On 03/13/19 at approximately 5:40 p.m., ASM (administrator staff member) #1 administrator, ASM #2, director of nursing, and ASM #3, regional director of operation, were made aware of the findings.
No further information was provided prior to exit.
Reference:
1. If you have anemia, your blood does not carry enough oxygen to the rest of your body. The most common cause of anemia is not having enough iron. This information was obtained from the website: https://medlineplus.gov/anemia.html - Health Topics
2. Conditions that cause heart attacks. Get more information on heart disease causes, types, and symptoms. This information was obtained from the website: https://www.health.com/condition/heart-disease
3. High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.
4. Alveolar hypoventilation is a rare disorder in which a person does not take enough breaths per minute. The lungs and airways are normal. This information was obtained from the website: https://medlineplus.gov/ency/article/000078.htm
5. Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html
6. A procedure for measuring the concentration of oxygen in the blood. The test is used in the evaluation of various medical conditions that affect the function of the heart and lungs. This information was obtained from the website: https://www.medicinenet.com/oximetry/article.htm#how_is_oximetry_done
3. The facility staff failed to administer Resident #55's oxygen according to the physician's order.
Resident #55 was admitted to the facility on [DATE]. Diagnoses for Resident #55 included but were not limited to Depression, Heart Failure, and Anxiety. Resident #55's Minimum Data Set (quarterly assessment) with an Assessment Reference Date of 02/08/2019 coded Resident #55 with moderate cognitive impairment. In addition, the Minimum Data set (MDS) coded Resident #55 as requiring existence assistance of one staff member with activities of daily living and limited assistance of one staff member with eating.
On 03/12/19 at approximately 11:20 a.m., Resident #55 was observed in bed receiving oxygen by nasal cannula from an oxygen concentrator. Observation of the oxygen concentrator flow meter documented the flow rate between two and two and a half liters per minute. A second surveyor also observed this observation at eye level of the flow meter.
On 03/12/2019, Resident #55's clinical record was reviewed. The review showed a physician order dated 02/06/2019 that documented, Oxygen at 2 liters per minute every shift for shortness of breath. Resident #55's care plan did not have oxygen as an intervention.
On 03/13/2019 at approximately 1:16 p.m., LPN (licensed practical nurse) #4 (the unit manager) was interviewed. LPN #4 was asked how staff ensure that resident's oxygen is on the correct setting. LPN #4 stated, You get down at eye level and make sure the ball on the flow meter is in the middle of the line. LPN #4 was asked why it is important to make sure the resident's oxygen is on the correct setting. LPN #4 stated, It is important because the resident needs it to avoid having respiratory distress. LPN #4 was made aware of the incorrect oxygen setting observed by two surveyors.
On 03/13/2019 at approximately 5:30 p.m., ASM (administrative staff member) #1 (the administrator), ASM #3 (the regional director of operations), ASM #2 (the director of nursing) were made aware of the above concern.
The facility document titled, Oxygen Concentrators, documented, Turn concentrator on and adjust liter flow (to that ordered by physician). Listen for startup alarm. The black liter flow ball on the gauge should be positioned in the middle of the number line (2.0, 2.5, 3.0, 3.5) prescribed by the physician. Liter flow should be checked by being eye level with flow meter. Attach oxygen delivery device to concentrator and place on guest.
No further information was presented prior to exit.
4. The facility staff failed to store Resident #23's respiratory equipment in a sanitary manner.
Resident #23 was admitted to the facility on [DATE]. Her diagnoses included Diabetes Mellitus Type 2 (a condition causing excessive sugar in the blood), Congestive Heart Failure (1), and Hypertension (high blood pressure). Resident #23's most recent Minimum Data Set (MDS) Assessment was an admission Assessment with an Assessment Reference Date (ARD) of 01/18/2019. The Brief Interview for Mental Status (BIMS) scored Resident #23 at 15, indicating no impairment. Resident #23 was coded as requiring extensive assistance of 1 person for bed mobility, transfers, dressing, toileting, and hygiene, and as requiring supervision and setup assistance for eating.
An initial tour of the facility was conducted on the morning of 03/12/2019. During the tour, an observation was made of Resident #23's room. It was noted that Resident #23 had a Continuous Positive Airway Pressure (CPAP)(2) device at the bedside. The mask of the device, attached via a flexible hose, was observed to be sitting uncovered on the nightstand.
During a follow up observation on the afternoon of 03/13/2019, Resident #23's CPAP mask was observed lying on the Resident's bed, covered by a plastic baggie. However, the hose of the CPAP was hanging off the edge of the bed and draped on the floor.
Administrative Staff Members (ASM) #1, the facility Administrator, and ASM #2, the Director of Nursing, were informed of these findings at the end of day meeting on 03/13/2019. The facility staff were asked to provide a copy of any facility policy regarding the storage or use of respiratory equipment.
On the morning of 03/14/2019, a brief interview was conducted with ASM #4, the Regional Clinical Coordinator. ASM #4 stated that the facility did not have a specific policy regarding storage or use of respiratory equipment, but rather that they followed their facility standards, which were stated to be [NAME].
From Infection prevention and control core practices: A roadmap for nursing practice, published by [NAME] in Nursing 2019: August 2018 - Volume 48 - Issue 8 - p 22-28:
Essential elements of standard precautions include: .
* Environmental cleaning and disinfection .
*reprocessing of reusable medical equipment
The article also notes, Surfaces, furniture, and equipment in patient rooms must be regularly cleaned and disinfected using agents approved by the Environmental Protection Agency for use in healthcare settings.
The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 03/14/2019. No further documentation was provided.
1. Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. The weakening of the heart's pumping ability causes: Blood and fluid to back up into the lungs, the buildup of fluid in the feet, ankles and legs - called edema, and tiredness and shortness of breath. - https://medlineplus.gov/heartfailure.html
2. Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. - https://medlineplus.gov/ency/article/001916.htm
Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services consistent with professional standards of practice for four of 53 residents in the survey sample, Residents # 9, # 104, # 55, and # 23.
1. The facility staff failed to store Resident # 9's BI-PAP [bi-level positive air pressure] (1) mask and tubing in a sanitary manner. During multiple observations of Resident 9's BI-PAP mask and tubing, revealed the mask was stored uncovered and not in a bag.
2. The facility staff failed to administer Resident #104's oxygen according to physician's orders.
3. The facility staff failed to administer Resident #55's oxygen according to the physician's order.
4. The facility staff failed to store Resident #23's respiratory equipment in a sanitary manner.
The findings include:
1. The facility staff failed to store Resident # 9's BI -PAP (continuous positive air pressure) mask and tubing in a sanitary manner.
Resident # 9 was admitted to the facility on [DATE] and a readmission on [DATE] with diagnoses that included but were not limited to: Parkinson's disease (2), multiple sclerosis (3), and sleep apnea (4).
Resident # 9's most recent comprehensive MDS (minimum [NAME] set) an annual assessment with an ARD (assessment reference date) of 07/09/18 coded the resident as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 being cognitively intact for daily decision-making. Resident # 9 was coded as requiring supervision and set up for activities of daily living and independent with eating. Section O Special Treatments, Procedures and Programs coded Resident # 9 as using a BI -PAP.
On 03/12/19 at 1:55 p.m., an observation of Resident # 9 revealed she was sitting in a chair next to her bed reading. Observation of Resident # 9's BI-PAP mask revealed it was hanging on the bed rail uncovered. The BI -PAP machine was sitting on top of the bedside table with the tubing connected to the machine. The other end of the tubing was uncovered, hanging down in front of the bedside table, and resting on the floor.
On 03/13/19 at 10:34 a.m., an observation of Resident # 9 sitting in a chair next to her bed reading. Observation of Resident # 9's BI-PAP mask revealed it was laying on the bed uncovered. The BI -PAP machine was sitting on top of the bedside table with the tubing connected to the machine. The other end of the tubing was uncovered, hanging down in front of the bedside table, and resting on the floor.
On 03/13/19 03:09 p.m., an observation of Resident # 9 revealed she was sitting in a chair next to her bed reading. Observation of Resident # 9's BI-PAP mask revealed it was laying on the bed uncovered. The BI -PAP machine was sitting on top of the bedside table with the tubing connected to the machine. The other end of the tubing was uncovered, hanging down in front of the bedside table, and resting on the floor.
The POS (physician's order sheet) dated 01/24/2019 for Resident # 9 documented, Bipap 16 cm (centimeters) h20 (hour) (BIPAP) sleeping every night. Start Date: 1/22/2017.
The comprehensive care plan dated 01/10/2019 for Resident # 9 documented, Need: (Resident # 9) has a potential for difficulty breathing and risk for respiratory complications R/T (related to): Obstructive Sleep Apnea. Date initiated 01/10/2019. Under Interventions it documented, Administer medication & (and) treatments per physician orders. Monitor for effectiveness, side effects and adverse reactions, report findings to the physician. BI-PAP. Date initiated: 01/10/2019.
On 03/13/19 at 4:04 p.m., an observation of Resident # 9's room and interview was conducted with LPN (licensed practical nurse) # 7. When asked to describe the procedure for storing a BI-PAP mask and tubing, LPN # 7 stated, It goes in plastic bag when not in use. When asked why the mask and tubing are stored in a plastic bag, LPN # 7 stated, To keep it clean. After observing the BI-PAP mask lying on the bed uncovered and the tubing hanging down in front of the bed side table with the end uncovered and resting on the floor, LPN # 7 stated, She (Resident # 9) does put it on and take it off. When asked if there was a plastic bag in Resident # 9's room to store the BI_PAP mask and/ or tubing, LPN # 7 stated, No. When asked if it is the residents or the nurse's responsibility to ensure the mask and tubing are stored correctly, LPN # 7 stated that the BI-PAP mask and tubing would be removed and cleaned.
On 03/14/19 at approximately 5:00 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, ASM # 3, regional director of operations, and ASM # 4, regional clinical coordinator were made aware of the findings.
No further information was provided prior to exit.
References:
(1) Stands for Bilevel Positive Airway Pressure, and is very similar in function and design to a CPAP machine (continuous positive airway pressure). Similar to a CPAP machine, A BiPAP machine is a non-invasive form of therapy for patients suffering from sleep apnea. Both machine types deliver pressurized air through a mask to the patient's airways. The air pressure keeps the throat muscles from collapsing and reducing obstructions by acting as a splint. Both CPAP and BiPAP machines allow patients to breathe easily and regularly throughout the night. This information was obtained from the website: https://www.alaskasleep.com/blog/what-is-bipap-therapy-machine-bilevel-positive-airway-pressure.
(2) A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html.
(3) A nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS. They can include visual disturbances, muscle weakness, trouble with coordination and balance, sensations such as numbness, prickling, or pins and needles and thinking and memory problems. This information was obtained from the website: https://medlineplus.gov/multiplesclerosis.html.
(4) Sleep apnea is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html.
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 and staff interview, the facility staff failed to prepare and serve food in a sanitary manner in the kitchen.
A dietary aide failed to secure their hair properly in a hair net, fa...
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Based on observation and staff interview, the facility staff failed to prepare and serve food in a sanitary manner in the kitchen.
A dietary aide failed to secure their hair properly in a hair net, failed to wash their hands before beginning food preparation, and touched the eating surface of food plates with un-gloved hands.
The findings include:
A tour of the facility kitchen was conducted on 03/12/2019 at 10:45a.m. An observation of the food preparation and tray line was conducted at 11:30a.m., with Other Staff Member (OSM) #14, a cook. At the beginning of the tray line, OSM #7, a Dietary staff member, was observed leaving the manager's office and walking directly to the tray line to begin assembling resident meal trays. OSM #7 was not observed washing their hands after leaving the manager's office, which entailed touching the doorknob, and was not wearing gloves.
During the tray assembly process, OSM #14 was observed filling trays with food, then placing them on top of the service line for OSM #7 to place onto trays, then OSM #7 placed those trays into the meal delivery cart. OSM #7 was observed grabbing the plates from the service line with un-gloved hands, and gripped the plates such that their thumb was pressed into the top, food-bearing surface of the plate.
Additionally, OSM #7 was observed wearing a hairnet, however OSM #7 had a long, dreadlocks-style haircut, and the ends of the dreadlocks extended down the back of their neck, to approximately- shoulder height, beyond the restraint of the hair net.
OSM #7 was eventually prompted by the interim Dietary Manager to was their hands and don gloves. The hairnet was not adjusted during tray line.
On the afternoon of 03/12/2019, a brief interview was conducted with OSM #14. When asked about how plates should be handled, OSM #7 stated gloves should be worn when handling meal trays and care should be taken to make sure the top surface was not touched. When asked about how a hairnet should be worn, OSM #7 stated that the hair should be completely covered.
Administrative Staff Member (ASM) #1, the facility Administrator, and ASM #2, the Director of Nursing, were informed of the findings at the end of day meeting on 03/13/2019. No further documentation was provided.
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
- "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 Virginia facilities.
Concerns
- • 54 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Laurels Of Willow Creek's CMS Rating?
CMS assigns THE LAURELS OF WILLOW CREEK an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Virginia, 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 The Laurels Of Willow Creek Staffed?
CMS rates THE LAURELS OF WILLOW CREEK's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 45%, compared to the Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Laurels Of Willow Creek?
State health inspectors documented 54 deficiencies at THE LAURELS OF WILLOW CREEK during 2019 to 2023. These included: 2 that caused actual resident harm, 51 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Laurels Of Willow Creek?
THE LAURELS OF WILLOW CREEK 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 CIENA HEALTHCARE/LAUREL HEALTH CARE, a chain that manages multiple nursing homes. With 120 certified beds and approximately 113 residents (about 94% occupancy), it is a mid-sized facility located in MIDLOTHIAN, Virginia.
How Does The Laurels Of Willow Creek Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, THE LAURELS OF WILLOW CREEK's overall rating (2 stars) is below the state average of 3.0, staff turnover (45%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Laurels Of Willow Creek?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?"
Is The Laurels Of Willow Creek Safe?
Based on CMS inspection data, THE LAURELS OF WILLOW CREEK has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Laurels Of Willow Creek Stick Around?
THE LAURELS OF WILLOW CREEK has a staff turnover rate of 45%, which is about average for Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Laurels Of Willow Creek Ever Fined?
THE LAURELS OF WILLOW CREEK 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 The Laurels Of Willow Creek on Any Federal Watch List?
THE LAURELS OF WILLOW CREEK 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.