ROSEDALE HEALTH & REHABILITATION
For profit - Limited Liability company
128 Beds
HILL VALLEY HEALTHCARE
Data: November 2025
Trust Grade
5/100
#274 of 285 in VA
Photo by Google Maps
Photo by Gruen Agency HCR - ManorCare
Photo by Rosedale Health & Rehabilitation
Photo by Rosedale Health & Rehabilitation
1 / 5 photos
Last Inspection: September 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Rosedale Health & Rehabilitation has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. They rank #274 out of 285 nursing homes in Virginia, placing them in the bottom half, and #10 out of 11 in Henrico County, meaning only one local option is better. The facility is worsening, with issues increasing from 6 in 2024 to 21 in 2025. Staffing is a major concern, with a poor rating of 1 out of 5 stars and a turnover rate of 66%, significantly higher than the state average. Additionally, the facility has faced $73,788 in fines, which is higher than 91% of Virginia facilities, suggesting ongoing compliance problems. Specific incidents include a resident sustaining a fractured femur due to staff failing to properly support them during transport in a wheelchair, and three residents not receiving appropriate assessments and treatments for pressure injuries, which led to harm. Although the facility has good quality measures, the overall performance is troubling, highlighting both strengths and serious weaknesses that families should consider carefully.
- Trust Score
- F
- In Virginia
- #274/285
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 66% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $73,788 in fines. Higher than 52% of Virginia facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 109 deficiencies on record. Higher than average. Multiple issues found across inspections.
5/100
Bottom 4%
Review needed
6 → 21 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 21 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
1-Star Overall Rating
Below Virginia average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 66%
20pts above Virginia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $73,788
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: HILL VALLEY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (66%)
18 points above Virginia average of 48%
The Ugly 109 deficiencies on record
4 actual harm
Apr 2025
19 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and facility document review, the facility staff failed to provide dignity and respect for two of 17 r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and facility document review, the facility staff failed to provide dignity and respect for two of 17 residents in the survey sample, Residents #4 and #9.
The findings include:
1. For Resident #4 (R4), the facility staff failed to speak to the resident in a respectful and dignified manner.
A grievance form regarding R4, dated 12/12/24 documented, Per sister, (name of RN [registered nurse] #4 [agency nurse]) was rude and abrasive (with) resident and sister after waiting for hours for someone. Per (name of sister), (name of RN #4) stated things like, 'I am busy too.' Per sister, not customer service appropriate. Initial Action: Date: 12/11/2024: Spoke (with) (name of RN #4). Per (name of RN #4) felt verbally abused by sister. However was abrasive with this unit manager as well. Follow Up Action: Date: 12/12/2024: RN to be DNR (do not return) from facility.
Resident council meeting minutes dated 12/18/24, 1/22/25, 2/19/25, and 3/19/25 documented, Nursing: Customer service issues/staff attitudes.
On 4/2/25 at 6:26 a.m., an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 stated the facility employs agency staff and there have been quite a few rude CNAs. CNA #6 stated that sometimes when a resident requests something, a staff member will state, Not now and walk off. CNA #6 stated she has also heard a resident request water and a staff member state, Didn't I just give you water. CNA #6 further stated she has heard a resident request their food be warmed up and a staff member state, No. I'm not warming it up.
On 4/2/25 at 12:02 p.m., an interview was conducted with LPN (licensed practical nurse) #8 (the nurse who documented the above grievance form). LPN #8 stated she did not personally hear RN #4 speak to R4 or the resident's sister, but she spoke to RN #4 on the phone regarding the above grievance. LPN #8 stated she did not know if RN #4 was stressed out from demands by R4's family but RN #4 was short, curt, and was not very customer friendly.
On 4/2/25 at 4:09 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, Dignity documented, 1. Residents will be treated with dignity and respect at all times.
No further information was presented prior to exit.
2. The facility failed to treat R9 in a respectful dignified manner.
Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences.
A review of the facility event synopsis dated 1/8/25 revealed, R9 alleged that aide used profanity when speaking with her. Review of staff interview revealed, R9 stated that she does not want aide in her room because she is rude. Review of interview with R9 on 1/8/25 revealed, The CNA (certified nursing assistant) was very rude. I asked her why she was being rude, and she became verbally aggressive.
An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked if she had been treated with dignity and respect, R9 stated, no, there is an aide that does not work with me anymore as she was rude and disrespectful. When asked if she had been treated in a dignified manner, R9 stated, no, I was not.
An interview was conducted on 3/31/25 at 12:00 PM with LPN (licensed practical nurse) #1. When asked if she had heard any staff being disrespectful to a resident. LPN #1 stated, yes, occasionally some of the agency staff will be short with the resident or use a hard tone of voice. When asked would this be considered verbal abuse, LPN #1 stated, no, no verbal abuse, just tone of voice mainly.
An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When CNA #7 was asked if she had heard any staff talking with residents disrespectfully, CNA #7 stated, yes, some staff do not speak in a nice tone. When asked if the residents are being treated with dignity, CNA #7 stated, no, they are not being treated with dignity.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Dignity policy revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff always speak respectfully to residents, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs.
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 F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet room change requirements prior to a room change for one of 17 re...
Read full inspector narrative →
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet room change requirements prior to a room change for one of 17 residents in the survey sample, Resident #3.
The findings include:
For Resident #3 (R3), the facility staff failed to provide a written notice of a room change and ensure the resident consented to the roommate assignment prior to the room change on 11/21/24.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/22/24, the resident scored 15 out of 15 on the (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented no behaviors observed during the assessment period and active discharge planning occurring for the resident to return to the community.
The admission record for R3 documented the resident as their own responsible party.
The census list for R3 documented a room change on 11/21/24 from Unit one private room to Unit two semi-private room.
The progress notes for R3 documented in part,
- 11/20/2024 16:04 (4:04 p.m.) Nursing note. Note Text: Met with resident in his room with DON (director of nursing), SW (social worker), Administrator, and Admissions Coordinator to discuss plans for rooms change. Resident was given teaching that he does not have a clinical need to remain in a private room and that Medicaid has not paid for him to remain in a private room. Based on these factors he will be moved to another room that is more appropriate for his clinical needs. Resident resistant to moving. He notified ombudsman to mediate. Ombudsman spoke with DON, SW, and Administrator via conference call. Room change deferred pending ombudsman review.
- 11/21/2024 13:38 (1:38 p.m.) Social services. Note Text: SW, DOA (director of admissions) and resident CNA (certified nursing assistant) went to resident room to assist in room change. Resident began yelling at DOA, telling her to get out and not to touch any of his things. He continued to yell at staff while they were helping pack his things in his room. As DOSS (director of social services) was trying to assist staff in packing, resident closed the DOSS hand in his dresser drawer while cussing and yelling get out, I don't want you in here. DOSS exited resident room along with DOA. CNA staff continued to pack resident and move him to his new room.
The clinical record failed to evidence documentation of written notice of a room change was provided to R3 or that R3 consented to the roommate assignment prior to the room change on 11/21/24.
On 4/2/25 at approximately 9:00 a.m., ASM (administrative staff member) #1, the administrator, stated that the director of nursing who wrote the nursing note on 11/20/24 at 4:04 p.m. no longer worked at the facility and could not be interviewed.
On 4/2/25 at 8:11 a.m., an interview was conducted with OSM (other staff member) #5, the director of social services, who stated that they worked with R3 at the facility. She stated that when a resident's room was going to be changed, she went in to speak to the resident to make sure the resident was going to be okay with the roommate, discuss the room change with both residents in the shared room, discuss it with the family, complete the room change assessment and make sure the residents agree to the room change. She stated that R3 was in a private room and was not paying private room prices. She stated that R3 had converted to LTC and was to be moved to a shared space, but he had refused to move for some time. OSM #5 stated that R3 had yelled at the staff, screamed at them and disrespected the staff. She stated that they had gone to R3 as a team to discuss why they had to make the room change and he continued to refuse to move from the private room, saying that he did not have to move. She stated that they discussed discharge home and R3 did not want to leave the facility. OSM #5 stated that on 11/21/24 they had gone into R3's room and talked to him again while the nursing staff were packing his things. She stated that R3 had yelled at her to get out of the room, and she had left the room to leave the nursing staff to complete the move. She stated that she remembered that R3 had viewed the new room prior to the move but she could not say that he had met the new roommate prior to the move. OSM #5 stated that residents could make the choice about room changes and she was certain that the business office manager had offered R3 the ability to keep the private room and given the pricing but he had refused. She stated that the business office manager no longer worked at the facility.
The facility policy, Room Change/Roommate Assignment dated 10/01/2021 documented in part, .Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice of the room change. Such notice will include the reason(s) why the move is recommended .
On 4/2/25 at 4:08 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical operations were made aware of the above concern.
No further information was presented 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 F0560
(Tag F0560)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to honor a resident's right to refuse a room change for one of 17 residents in the survey sample, Resident #3.
The findings include:
For Resident #3 (R3), the facility staff failed to honor a resident's right to refuse a room change on 11/21/24.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/22/24, the resident scored 15 out of 15 on the (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented no behaviors observed during the assessment period and active discharge planning occurring for the resident to return to the community.
The admission record for R3 documented the resident as their own responsible party.
The census list for R3 documented an admission to Unit one to a private room with a room change on 11/21/24 to Unit two to a semi-private room.
The progress notes for R3 documented in part,
- 11/20/2024 16:04 (4:04 p.m.) Nursing note. Note Text: Met with resident in his room with DON (director of nursing), SW (social worker), Administrator, and Admissions Coordinator to discuss plans for rooms change. Resident was given teaching that he does not have a clinical need to remain in a private room and that Medicaid has not paid for him to remain in a private room. Based on these factors he will be moved to another room that is more appropriate for his clinical needs. Resident resistant to moving. He notified ombudsman to mediate. Ombudsman spoke with DON, SW, and Administrator via conference call. Room change deferred pending ombudsman review.
- 11/21/2024 13:38 (1:38 p.m.) Social services. Note Text: SW, DOA (director of admissions) and resident CNA (certified nursing assistant) went to resident room to assist in room change. Resident began yelling at DOA, telling her to get out and not to touch any of his things. He continued to yell at staff while they were helping pack his things in his room. As DOSS (director of social services) was trying to assist staff in packing, resident closed the DOSS hand in his dresser drawer while cussing and yelling get out, I don't want you in here. DOSS exited resident room along with DOA. CNA staff continued to pack resident and move him to his new room.
On 4/2/25 at approximately 9:00 a.m., ASM (administrative staff member) #1, the administrator, stated that the director of nursing who wrote the nursing note on 11/20/24 at 4:04 p.m. no longer worked at the facility and could not be interviewed.
On 4/2/25 at 8:11 a.m., an interview was conducted with OSM (other staff member) #5, the director of social services, who stated that they worked with R3 at the facility. She stated that when a resident's room was going to be changed, she went in to speak to the resident to make sure the resident was going to be okay with the roommate, discuss the room change with both residents in the shared room, discuss it with the family, complete the room change assessment and make sure the residents agree to the room change. She stated that R3 was in a private room and was not paying private room prices. She stated that R3 had converted to LTC (long term care) and was to be moved to a shared space, but he had refused to move for some time. OSM #5 stated that R3 had yelled at the staff, screamed at them and disrespected the staff. She stated that they had gone to R3 as a team to discuss why they had to make the room change and he continued to refuse to move from the private room, saying that he did not have to move. She stated that they discussed discharge home and R3 did not want to leave the facility. OSM #5 stated that on 11/21/24 they had gone into R3's room and talked to him again while the nursing staff were packing his things. She stated that R3 had yelled at her to get out of the room, and she had left the room to leave the nursing staff to complete the move. She stated that she remembered that R3 had viewed the new room prior to the move but she could not say that he had met the new roommate prior to the move. OSM #5 stated that residents could make the choice about room changes and she was certain that the business office manager had offered R3 the ability to keep the private room and given the pricing but he had refused. She stated that the business office manager no longer worked at the facility.
On 4/2/25 at 10:30 a.m., an interview was conducted with OSM #8, the director of admissions who stated that R3 was moved on 11/21/24 due to the room being needed for isolation for a new admission. She stated that they had given R3 the option to pay for the private room and he had refused so they had completed the room change later that day. She stated that she did not have any documentation regarding this, but the social worker and former director of nursing had documented this. At that time a request was made to ASM #1, the administrator for evidence of the census on 11/21/24 with available rooms, and evidence of a private isolation room needed for the new resident.
On 4/2/25 at 11:52 a.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that they remembered R3 was not happy with moving from a private to a semiprivate room. She stated that after the first night he was moved he stayed out of the facility and did not notify them and then not long after that he was discharged . She stated that she thought that the room change had to do with a payer change.
On 4/2/25 at approximately 1:30 p.m., ASM #1 and OSM #8 provided documents for Resident #17 who was admitted to the facility on [DATE] which failed to evidence an isolation need. Review of R17's clinical record failed to evidence isolation while a resident at the facility. The empty locations list for 11/21/2024 documented two empty semi-private rooms and failed to evidence private rooms.
On 4/2/25 at 2:15 p.m., an interview was conducted with ASM #1 who stated that R17 was not on isolation and that the private room need may have been for behaviors. She stated that one of the empty semi-private rooms on Unit one was undergoing renovations on 11/21/24 and was still closed. She stated that the other empty semi-private room could have been an option for R3, but they would have had to look at the size of the room for R3's bed and there were no other private rooms open on 11/21/24. She stated that R3 was not forced out the room because they had explained to him that they needed the room for another resident who could be coming. ASM #1 stated that they had discussed with R3 that if he wanted a private room, he had to pay the private room rate and he basically said no. She stated that he decided to transition to LTC, and she was there the day of the move when there was a lot of cursing and telling them to get out. In a follow up interview at 3:56 p.m., ASM #1 was asked what it meant to transition to LTC. ASM #1 stated that R3 had originally admitted for short term for a stay about 30 days but had decided that he wanted to stay long term. She stated that even though they were dually certified, they tried to keep the LTC residents on Unit 2. She stated that they tried to keep Unit 1 as the post-acute unit. ASM #1 stated that they had 128 beds total, and all beds were dually certified. When asked what the clinical need was for R3 to have the private room on admission, she stated that she was not aware of what it was.
The facility policy, Room Change/Roommate Assignment dated 10/01/2021 documented in part, .Residents have the right to refuse to move to another room in the facility if the purpose of the move is: a. To relocate the resident from a skilled nursing unit within the facility to one that is not a skilled nursing unit; b. To relocate the resident from a nursing unit with the facility to one that is a skilled nursing unit; or c. Solely for the convenience of the staff .
On 4/2/25 at 4:08 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical operations were made aware of the above concern.
No further information was presented 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.a. For Resident #1 (R1), the facility staff failed to notify the physician or nurse practitioner in a timely manner when the antibiotic medication Ertapenem was not available for administration.
A r...
Read full inspector narrative →
2.a. For Resident #1 (R1), the facility staff failed to notify the physician or nurse practitioner in a timely manner when the antibiotic medication Ertapenem was not available for administration.
A review of R1's clinical record revealed a urine culture report dated 11/11/24 that documented the resident presented with a urinary tract infection. Further review of R1's clinical record revealed a physician's order dated 11/11/24 for Ertapenem Sodium Solution- one gram intravenously every 24 hours for infection for seven days. Pharmacy alerts dated 11/11/24 documented a possible drug allergy and a possible drug interaction for Ertapenem. Administration notes dated 11/12/24 and 11/13/24 documented the nurses were waiting for the pharmacy to send Ertapenem. An administration note dated 11/14/24 documented, Pharmacy originally would not fill (Ertapenem) because of an allergy alert. Per NP (nurse practitioner) (name) it is ok for resident to take this drug, as she has been given it before. Per pharmacy medication will be delivered today. A review of R1's November 2024 medication administration record and a nurse's note dated 11/15/24 revealed R1 was not administered the first dose of Ertapenem until 11/15/24 (four days after the medication was ordered).
On 4/2/25 at 10:10 a.m., an interview was conducted with ASM (administrative staff member) #6 (the nurse practitioner). ASM #6 stated the importance of immediately starting an antibiotic is to prevent the resident from going septic. ASM #6 stated she enters medication orders into the computer system then the nurses have to activate the orders. ASM #6 stated that when the nurses activate the orders, the system tells them if there are possible allergies or drug interactions. ASM #6 stated the nurses should call her as soon as they receive the alerts. ASM #6 stated that once she enters an order, she assumes the pharmacy will send the medication and if the medication does not come, it is the nurses' responsibility to notify her.
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that when a nurse activates orders in the computer system and there are possible allergy or drug interactions, the system alerts the nurse before she saves the orders. LPN #7 stated right then and there, the nurse should contact the pharmacy and immediately call the physician or nurse practitioner.
On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
No further information was presented prior to exit.
2.b. For Resident #1 (R1), the facility staff failed to notify the resident representative when the resident's blood sugar read, High and the nurse practitioner ordered additional insulin.
A review of R1's clinical record revealed a nurse's note dated 12/13/24 that documented, Resident blood glucose recording HI, Rechecked several times. Insulin lispro 15 mls (milliliters) administered subcutaneously, and 18 units of glargine insulin administered. Glucose continued to read high 30 min later. Message sent to NP (nurse practitioner), order to administer an additional 12 units of lispro insulin and recheck the glucose 2 hours later received. Further review of R1's clinical record failed to reveal R1's representative was notified regarding the high blood sugar and the order for additional insulin.
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated a resident's representative should be called if the resident's blood sugar reads, High and the nurse practitioner orders additional insulin.
On 4/2/25 at 2:23 p.m., an interview was conducted with RN (registered nurse) #3 (the nurse who documented the above nurse's note). RN #3 stated she did not remember calling R1's representative when the resident's blood sugar read, High and the nurse practitioner ordered additional insulin.
On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
No further information was presented prior to exit.
Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician/nurse practitioner and/or the responsible party of resident changes for two of 17 residents in the survey sample, Residents #6 and #1.
The findings include:
1. For Resident #6 (R6), the facility staff failed to notify the responsible party and physician of refusal of care and a change in behavior on 7/26/24.
On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 7/28/24, the resident scored three out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented physical and verbal behaviors directed towards others one to three days during the assessment period.
The progress notes for R6 documented in part,
- 7/24/2024 21:56 (9:56 p.m.) Note Text: resident arrived via stretcher from home, resident here for respite care. resident alert with some confusion. resident is a high fall risk. skin tear to left forearm. resident takes meds whole. regular diet. hydration at bedside call bell in reach, will cont. to monitor for needs and safety.
- 7/25/2024 02:14 (2:14 a.m.) .Cognitive status assessed. Resident is cognitively intact. Oriented to person. Oriented to place. Oriented to time. Behavior/mood evaluated, and the resident is noted to be uncooperative .
- 7/26/2024 05:41 (5:41 a.m.) Note Text: Accucheck. one time a day Notify physician for BG <70 or >400
Patient refused, kicking, using derogatory language and spitting at staff.
- 7/26/2024 06:42 (6:42 a.m.) Note Text: The resident's behavior became combative, including the use of derogatory language, spitting, kicking, and even biting at the staff. Despite this RN (registered nurse) and a second person nursing assistance inquiring about how they could assist him, the aggression only intensified. The resident began yelling and kicking, complicating the situation further. Additionally, the resident continued to remove his clothes and briefs. In response, this RN and nursing assistant decided to step away from the resident while ensuring his safety, leaving the bed in the lowest position and the call bell within reach.
- 7/28/2024 01:11 (1:11 a.m.) .Cognitive status assessed. Resident is cognitively intact. Oriented to person. Oriented to place. Oriented to time. Behavior/mood evaluated, and the resident is noted to be uncooperative .
- 7/29/2024 01:51 (1:51 a.m.) .Cognitive status assessed. Resident is cognitively intact. Oriented to person. Oriented to place. Oriented to time. Behavior/mood evaluated, and the resident is noted to be uncooperative .
The progress notes failed to evidence documentation of physical behaviors towards others or refusal of care on dates other than 7/26/24. The clinical record failed to evidence notification of the physician or the responsible party of the change in behavior with physical aggression towards staff observed on 7/26/24.
On 4/2/25 at approximately 9:00 a.m., ASM (administrative staff member) #1, the administrator stated that the RN (registered nurse) who documented the progress note regarding the physical aggression observed on 7/26/24 no longer worked at the facility and could not be interviewed.
On 4/2/25 at 6:09 a.m., an interview was conducted with CNA (certified nursing assistant) #6 who stated that they worked with R6 when they were at the facility. She stated that she remembered that R6 had become very confused and anxious when he woke up that morning and became very upset about something. She stated that when she went in the room he had started yelling, spitting and kicking and she had called for the nurse. She stated that they had not touched R6 and had made sure he was safe and left him in the room to calm down.
On 4/2/25 at 11:20 a.m., an interview was conducted with LPN (licensed practical nurse) #7 who stated that the responsible party should be notified of changes in condition or anything out of the normal. She stated that when a resident refused medications or care they attempted at least and if they still refused, they let the physician, and the responsible party know. She stated that if a resident had a change in behavior, they would call the physician with concern for a urinary tract infection or if the resident was a new admission she would contact the family to discuss their normal behavior and see what was done to deescalate the behavior.
On 4/2/25 at 1:28 p.m., ASM #2, the director of nursing stated that they did not have any evidence to provide that the RP or MD were notified of the refusal of the accuchecks or the behavioral incident on 7/26/24. She stated that there was no investigation completed into the behavioral incident on 7/26/24.
The facility policy, Change in a Residents Condition, documented in part, .The facility will promptly notify the resident, his or her physician/practitioner, and the representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been a(an) . d. significant change in the resident's physical, mental, or psychosocial status . Unless otherwise instructed by the resident, a nurse will notify the resident's representative when . b. There is a significant change in the resident's physical, mental, or psychosocial status .
On 4/2/25 at 4:08 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were made aware of the above concern.
No further information was obtained 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the faci...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide a safe/clean and homelike environment for three of 17 residents, R9, R11 and R15.
The findings include:
1. The facility staff failed to maintain a clean and homelike environment for Resident #9.
Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences.
On 3/31/25 at 12:30 PM observed R9's room. Room had peeling wallpaper at the seams, and behind headboard of bed two 8.5 x 11 inches and one approximately 3 x 18 inches of spackled dry wall.
When ask about the room and wall spackling, R9 stated, they told me it was due to the bed rubbing on the wall. The plan is for them to renovate room [ROOM NUMBER], then move me to that room and renovate this room.
An interview was conducted on 4/2/25 at 9:00 AM with OSM (other staff member) #6, the maintenance director. When shown R9's room with peeling wallpaper at seams and spackling compound over holes in walls behind headboard, OSM #6 stated, the renovation started with the halls and lobby. We will then move to resident rooms. Our plan is to renovate room [ROOM NUMBER], move this resident to that room, then renovate this room. When asked if this is a clean and homelike environment, OSM # stated, no, when you ask those questions, it is not.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Homelike Environment policy revealed, Residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
No further information was provided prior to exit.
2. The facility staff failed to maintain a clean/homelike environment and provide linens for Resident #11.
Resident #11 (R11) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Parkinson's Disease, convulsions and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 3/31/25 revealed, FOCUS: The resident is frequently incontinent of bladder and bowels. INTERVENTIONS: Provide substantial/maximal assistance with toileting.
On 3/31/25 at 1:30 PM observed R11's room. Room had peeling wallpaper at the seams on three walls.
When ask about the room and wall spackling, R11 stated, yes, it has been like this for a while.
An interview was conducted on 3/31/25 at 8:00 AM with OSM (other staff member) #1, the laundry aide. When asked if there is a stained or torn linen, OSM #1 stated, no, I would not put it out if it were stained or torn. I will be bringing linen out to the unit shortly.
Observations on 3/31/25 at 8:20 AM revealed, Unit 1: 4 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns; Unit 2: 2 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns.
An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the linen and supplies, they need, CNA #1 stated, no, we do not have enough linen and we run out of supplies.
An interview was conducted on 3/31/25 at 10:35 AM when R11, who had rolled his wheelchair up to the nursing station to ask for a towel and washcloth. CNA #3 told R11, we do not have any right now, I will bring you some as soon as we have them. When R11 was asked how often there is not linen, towels/washcloths for him in the morning, R11 stated, it happens a lot, it is late morning before we have linen.
An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked about linens, CNA #3 stated, we are out of linen, and they have not delivered any this morning. We cannot bathe our residents or even provide incontinence care because there are no towels and washcloths.
An interview was conducted on 4/2/25 at 9:00 AM with OSM (other staff member) #6, the maintenance director. When shown R11's room with peeling wallpaper at seams, OSM #6 stated, the renovation started with the halls and lobby. We will then move to resident rooms. Our plan is to renovate room [ROOM NUMBER], move a resident into that room and then go down the line in order to renovate the rooms. When asked if this is a clean and homelike environment, OSM # stated, no, when you ask those questions, it is not.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Homelike Environment policy revealed, Residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in a good condition.
No further information was provided prior to exit.
3. The facility staff failed to provide linens for Resident #15.
Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode.
An interview was conducted on 3/31/25 at 8:00 AM with OSM (other staff member) #1, the laundry aide. When asked if there is a stained or torn linen, OSM #1 stated, no, I would not put it out if it were stained or torn. I will be bringing linen out to the unit shortly.
Observations on 3/31/25 at 8:20 AM revealed, Unit 1: 4 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns; Unit 2: 2 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns.
Observations on 4/1/25 at 6:05 AM revealed, Unit 1: 2 pillowcases and 1 each fitted and flat sheet. Zero towels, washcloths or gowns; Unit 2: 15 pillowcases, 2 washcloths, 9 towels, 3 blanket and 1 gown. Zero fitted or flat sheets or blankets.
An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the linen and supplies, they need, CNA #1 stated, no, we do not have enough linen and we run out of supplies.
An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked about linens, CNA #3 stated, we are out of linen, and they have not delivered any this morning. We cannot bathe our residents or even provide incontinence care because there are no towels and washcloths.
An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had supplies, linen and snacks they need for the residents. CNA #7 stated a lot of the time we do not have linen for the residents. CNA #7 stated, there is a resident who wants to speak to the state about snacks and linen, CNA you talk with her.
An interview was conducted on 4/1/25 at 5:45 AM with R15. R15 stated, this is the fifth day there has not been linen in the morning. I am so tired of this. I have had to use a pillowcase to wash and dry my face. They cannot clean you up, because there is no linen.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Homelike Environment policy revealed, The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in a good condition.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the faci...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop the care plan for one of 17 residents in the survey sample, R9.
The findings include:
The facility staff failed to develop the comprehensive care plan for PICC (peripherally inserted central catheter) /midline care for R9.
Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. There is no evidence of PICC/midline on R9's care plan.
A review of the progress note dated 3/10/25 at 6:30 PM revealed, Received resident lying in bed on left side with eyes open. Resident informed that I would be removing her PICC line from her right upper arm. Dressing removed, PICC site cleansed, PICC line removed without difficulty. Catheter tip intact and measures 20cm. Resident denies pain or distress, tolerated well. Pressure dressing applied. Resident encouraged to notify charge nurse if site begins to bleed or is painful. Resident stated understanding.
An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked if she had any lines or catheters, R9 stated, there was a PICC line for antibiotics, but it was removed.
An interview was conducted on 4/2/25 at 12:20 PM with LPN (licensed practical nurse) #8. When asked the care plan purpose, LPN #8 stated, it is so nursing staff know how to care for the resident. When asked if a midline should be on care plan, LPN #8 stated yes, special needs should be on the care plan. Here nursing team develops the care plan.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
No policy for care plan provided.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide pharmacy services for one of 17 residents in the survey sample, Resident #4.
The fi...
Read full inspector narrative →
Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide pharmacy services for one of 17 residents in the survey sample, Resident #4.
The findings include:
For Resident #4 (R4), the facility staff failed to obtain medications for administration.
A review of R4's clinical record revealed physician's orders dated 12/3/24 for Verapamil 240 mg (milligrams)-one tablet by mouth at bedtime for high blood pressure and Prazosin 2 mg-one capsule by mouth at bedtime for HTN (hypertension [high blood pressure]). R4's December 2024 MAR (medication administration record) revealed the same physician's orders. Further review of R4's December 2024 MAR failed to reveal Verapamil and Prazosin was administered on 12/24/24 (as evidenced by blank spaces on the MAR).
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that if a medication is not available for administration, then nurses should check the Omnicell (a machine containing various medications). LPN #7 stated that if the medication is not available in the Omnicell, then nurses should contact the pharmacy, re-order the medication, and call the provider (physician or nurse practitioner) to obtain an order for an alternative medication or put the medication on hold.
A review of the Omnicell list revealed Verapamil and Prazosin was not available in the Omnicell.
On 4/2/25 at 4:09 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 pharmacy policy titled, General Guidelines for Medication Administration documented, II. Administration: 2. Medications are administered in accordance with written orders of the prescriber.
No further information was presented 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 F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to evidence radiology serv...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to evidence radiology services as ordered for one of 17 residents, R8.
The findings include:
Resident #8 (R8) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CVA (cerebrovascular accident) with hemiplegia, hemiparesis and vascular dementia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/5/24, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as being dependent for turning.
A review of the comprehensive care plan dated 8/21/24 revealed, FOCUS: The resident has an ADL (activities of daily living) self-care performance deficit due to history of CVA, dementia. He is dependent on staff for all ADL needs. INTERVENTIONS: BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed and as necessary.
A review of the physician's order dated 12/16/24 revealed, CXR one time only for productive cough for 1 day.
A review of the progress notes dated 12/18/24 at 12:27 AM revealed, attempted to call to schedule a chest Xray but voice recording says to call back during regular business hours. Will pass this forward to 7-3p shift for action and follow-up with this call.
A review of the progress notes dated 12/18/24 at 1:35 PM revealed, Call placed to Dispatch Health Imaging. Per representative, no longer takes new orders 24/7. Only able to place orders up until 11:00 PM. CXR ordered at this time.
A review of the chest x-ray results obtained on 12/19/24 at 6:00 AM and resulted on 12/19/24 at 4:45 PM revealed, There has been no significant change compared with the prior exam. Impression: The lungs show no confluent airspace opacity.
An interview was conducted on 4/2/25 at 10:35 AM with ASM (administrative staff member) #7, the nurse practitioner. When asked expected time frame for a chest x-ray completion, ASM #7 stated, normally we would get the x-ray and results within 24 hours. I do not know if the imaging calls for critical results.
ASM #1, the administrator stated on 4/3/25 at 9:00 AM, there is nothing more to provide to you.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Radiology and Diagnostic Services policy revealed, Radiological and diagnostic testing services are provided by the facility to meet the needs of our residents. The services may be provided on-site or off-site through contracted services of a diagnostic testing provider that is approved to provide the services by Medicare.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 17 residents in the survey sample, Resident #1.
The findi...
Read full inspector narrative →
Based on staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 17 residents in the survey sample, Resident #1.
The findings include:
For Resident #1 (R1), the facility staff failed to document the resident's blood sugar reading on 12/13/24 at 3:59 a.m.
A review of R1's clinical record revealed a physician's order dated 12/13/24 that documented, Recheck blood glucose at 0200 (2:00 a.m.) A review of R1's December 2024 medication administration record revealed the resident's blood sugar was re-checked on 12/13/24 at 3:59 a.m. Further review of R1's clinical record (including the December 2024 medication administration record, nurses' notes, and blood sugar summary) failed to reveal documentation of the numerical reading of the resident's blood sugar when it was re-checked on 12/13/24 at 3:59 a.m.
On 4/2/25 at 3:23 p.m., an interview was conducted with LPN #9 (the nurse who signed off re-checking R1's blood sugar at 3:59 a.m.) LPN #9 stated that when a nurse checks a resident's blood sugar, the number should be documented on the medication administration record. LPN #9 stated she did not remember R1.
On 4/2/25 at 4:09 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 did not have a policy regarding a complete and accurate clinical record.
No further information was presented prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**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 follow professional...
Read full inspector narrative →
**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 follow professional standards of practice for three of 17 residents in the survey sample, Residents #1, #4, and #9.
The findings include:
1. For Resident #1 (R1), the facility staff failed to follow the physician's order to call the physician for a blood sugar greater than 400, prior to administering insulin.
A review of R1's clinical record revealed the following orders:
-12/5/24-Insulin Glargine Solostar Subcutaneous Solution Pen-injector 300 UNIT/ML (milliliters). Inject 18 unit
subcutaneously at bedtime for diabetes.
-12/10/24-Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject as per sliding scale before meals and at bedtime for diabetes:
if (blood sugar) 150-199=8 units
200-249=9 units
250-299=10 units
300-349=12 units
350-399=15 unit
Blood sugars over 400, call MD (medical doctor).
A nurse's note dated 12/13/24 (at 12:25 a.m.) documented, Resident blood glucose recording HI (over 400), Rechecked several times. Insulin lispro 15 mls (milliliters) administered subcutaneously, and 18 units of glargine insulin administered. Glucose continued to read high 30 min later. Message sent to NP (nurse practitioner), order to administer an additional 12 units of lispro insulin and recheck the glucose 2 hours later received.
On 4/2/25 at 11:19 a.m., the above lispro insulin sliding scale order was reviewed with LPN (licensed practical nurse) #7. LPN #7 stated some sliding scale insulin orders document to give a certain amount of insulin and call the physician for a blood sugar over a certain level, but that order did not. LPN #7 stated the above order documented to call the physician for a blood sugar over 400 so she would immediately call the physician before administering the insulin.
On 4/2/25 at 2:23 p.m., an interview was conducted with RN (registered nurse) #3 (the nurse who documented the above nurse's note). RN #3 stated R1's blood sugar read, High so she administered insulin, gave time for the medication to respond, re-checked R1's blood sugar, then contacted the nurse practitioner.
On 4/2/25 at 4:09 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 and Treatment Orders documented, 1. Medications will be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.
No further information was presented prior to exit.
2. For Resident #4 (R4), the facility staff failed to administer multiple medications in a timely manner.
A review of R4's clinical record revealed the following physician's orders:
12/3/24-Gabapentin 100 mg (milligrams). Give one capsule by mouth three times a day for pain.
12/3/24-Furosemide 80 mg. Give one tablet by mouth one time a day for HTN (hypertension [high blood pressure]).
12/3/24-Novolog FlexPen 100 units/ml (milliliter). Inject 22 units subcutaneously one time a day for diabetes.
12/3/24-Tiotropium Bromide 18 mcg (micrograms). One capsule inhale orally one time a day to prevent bronchospasms.
12/3/24-Sennosides-Docusate Sodium 8.6-50 mg. Give one tablet by mouth one time a day for constipation.
12/3/24-MiraLax 17 gm (grams)/scoop. Give one scoop by mouth one time a day for constipation.
12/5/24-Clopidogrel Bisulfate 75 mg. Give 75 mg by mouth one time a day for CVA (cerebrovascular accident [stroke]).
A review of a medication administration audit report for December 2024 revealed the following:
-Gabapentin was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 1:00 p.m. on 12/16/24.
-Furosemide was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:14 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 1:00 p.m. on 12/16/24.
-Novolog was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 1:09 p.m. on 12/16/24.
-Tiotropium bromide was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:12 p.m. on 12/15/24, and 1:11 p.m. on 12/16/24.
-Sennosides-Docusate Sodium was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:14 p.m. on 12/14/24, 1:12 p.m. on 12/15/24, and 1:09 p.m. on 12/16/24.
-MiraLAX was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:12 p.m. on 12/15/24, and 1:09 p.m. on 12/16/24.
-Clopidogrel Bisulfate was scheduled at 9:00 and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 12:57 p.m. on 12/16/24.
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated nurses should administer medications within one hour before or one hour after a medication is scheduled because that is when the medications are ordered. LPN #7 stated medications administered after one hour the medications are scheduled are late and kind of like a medication error.
On 4/2/25 at 4:09 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 pharmacy policy titled, General Guidelines for Medication Administration documented, II. Administration: 12. Medications are administered within 60 minutes of the scheduled administration time .
No further information was presented prior to exit.
3.The facility staff failed to meet professional standards by clarifying medication orders and administering medications timely for R9.
A. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences.
A review of the physician orders dated 10/15/24 revealed, Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy at 4:00 AM. Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy at 6:00 AM.
An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked if medications were administered timely, R9 stated, no, they are late, particularly the 6:00 AM and evening ones.
An interview was conducted on 4/2/25 at 6:15 AM with LPN (licensed practical nurse) #5. When asked about the medication order for Modafinil for R9, how to read it, LPN #5 stated, it is ordered to give it one time a day, but there are two different times for it to be administered. When asked if the order should be clarified, LPN #5 stated, yes, it should be clarified. When asked where evidence of the clarification would be, LPN #5 stated, we usually write it in the physician communication book or in the progress notes. The pharmacy has told us that we run out of the medication because we are giving too much.
On 4/2/25 at 8:00 AM, a request of the facility to provide evidence of clarification of this order with the physician/nurse practitioner (NP).
An interview was conducted on 4/2/25 at 10:00 AM with ASM (administrative staff member) #6, the nurse practitioner. When asked about the Modafinil order for once a day but ordered for two different times, ASM #6 stated, when she first got here, I changed the order for the Modafinil (treatment for narcolepsy) because she had bradycardia with the full dose. So, I ordered it as once a day at 4:00 AM and 6:00 AM, two hours apart, so I split the order so one at 4:00 AM and one at 6:00 AM. When asked if the order should be clarified, ASM #6 stated, yes, it could be ordered twice a day and specify the times of administration. That would be clearer. When asked if she was aware that per the nurse, pharmacy is not filling the medication to give two doses in one day as currently prescribed, ASM #6 stated, no, I was not aware of that. I will change the order.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's General Guidelines for Medication Administration policy revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer.
No further information was provided prior to exit.
B. A review of the physician orders dated 10/8/24 revealed, Acarbose Tablet 25 MG Give 1 tablet by mouth three times a day for diabetes. Metoprolol Tartrate Oral Tablet 50 MG, Give 1 tablet by mouth three times a day for HTN. A review of the physician order dated 10/14/24 revealed, Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy AND Give 1 tablet by mouth one time a day for narcolepsy.
A review of the March 2025 MAR (medication administration record) reveals, Acarbose Tablet 25 MG Give 1 tablet by mouth three times a day for diabetes, scheduled for 9:00 AM, 2:00 PM and 6:00 PM; was administered at: 3/1-7:58 PM, 3/9-8:26 PM, 3/11 8:54 PM, 3/27 12:14 AM (for 6 PM dose 3/26). Metoprolol Tartrate Oral Tablet 50 MG Give 1 tablet by mouth three times a day for HTN, scheduled for 6:00 AM, 2:00 PM and 10:00 PM; was administered at: 3/14-11:41 PM, 3/23 12:57 AM (for 6 PM dose 3/22), 3/27 12:15 AM (for 6 PM dose 3/26). Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy, scheduled administration time 4:00 AM; was administered at: 3/1-5:45 AM, 3/5-5:56 AM, 3/11-5:32 AM, 3/22-5:50 AM, 3/23-5:20 AM, 3/24-5:35 AM, 3/25-5:36 AM and 3/28-5:26 AM.
An interview was conducted on 4/2/25 at 11:20 AM with LPN (licensed practical nurse) #7. When asked the medication administration time frames, LPN #7 stated, the med should be given within one hour before or after the scheduled time of administration. When asked why, LPN #7 stated, because it is when it is ordered. Otherwise, it is late or given outside of order parameters.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's General Guidelines for Medication Administration policy revealed, Medications are administered within 60 minutes of the scheduled administration time.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staf...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for a dependent resident for one of 17 residents, R8.
The findings include:
Resident #8 (R8) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CVA (cerebrovascular accident) with hemiplegia, hemiparesis and vascular dementia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/5/24, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as being dependent for turning.
A review of the comprehensive care plan dated 8/21/24 revealed, FOCUS: The resident has an ADL (activities of daily living) self-care performance deficit due to history of CVA, dementia. He is dependent on staff for all ADL needs. INTERVENTIONS: BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed and as necessary.
A review of the ADL form for November and December 2024 revealed, the following dates and shifts of missing documentation: Day shift-11/6, 11/7, 11/14, 11/27, 12/14, 12/20, 12/24 and Evening shift-11/9, 11/25, 11/27 and 12/20; Night shift-11/3, 11/8, 11/14, 11/18, 11/29, 11/30, 12/22 and 12/25.
An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. When CNA #4 was asked where evidence of the resident being turned and positioned and head of bed elevated would be evidenced. CNA #4 stated, it is documented on the ADL form. When asked if there were blanks in the documentation, was the turning/positioning and head of bed elevated done, CNA #4 stated, no, it was not done.
An interview was conducted on 4/1/25 at 5:30 AM with CNA #6. When asked about turning/positioning and head of bed being elevated, CNA #6 stated, we document on the ADL form and if it is not documented, it is not done.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. For Resident #1 (R1), the facility staff failed to administer a physician ordered intravenous antibiotic in a timely manner...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. For Resident #1 (R1), the facility staff failed to administer a physician ordered intravenous antibiotic in a timely manner.
A review of R1's clinical record revealed a urine culture report dated 11/11/24 that documented the resident presented with a urinary tract infection. Further review of R1's clinical record revealed a physician's order dated 11/11/24 for Ertapenem Sodium Solution- one gram intravenously every 24 hours for infection for seven days. Pharmacy alerts dated 11/11/24 documented a possible drug allergy and a possible drug interaction for Ertapenem. Administration notes dated 11/12/24 and 11/13/24 documented the nurses were waiting for the pharmacy to send Ertapenem. An administration note dated 11/14/24 documented, Pharmacy originally would not fill (Ertapenem) because of an allergy alert. Per NP (nurse practitioner) (name) it is ok for resident to take this drug, as she has been given it before. Per pharmacy medication will be delivered today. A review of R1's November 2024 medication administration record and a nurse's note dated 11/15/24 revealed R1 was not administered the first dose of Ertapenem until 11/15/24 (four days after the medication was ordered).
A review of the Omnicell list revealed one-gram vials of ertapenem were available in the Omnicell (a machine in the facility that contains various medications).
On 4/2/25 at 10:10 a.m., an interview was conducted with ASM (administrative staff member) #6 (the nurse practitioner). ASM #6 stated the importance of immediately starting an antibiotic is to prevent the resident from going septic.
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that when a nurse activates orders in the computer system and there are possible allergy or drug interactions, the system alerts the nurse before she saves the orders. LPN #7 stated right then and there, the nurse should contact the pharmacy and immediately call the physician or nurse practitioner.
On 4/2/25 at 4:09 p.m., ASM #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility pharmacy policy titled, General Guidelines for Medication Administration documented, II. Administration: 2. Medications are administered in accordance with written orders of the prescriber.
No further information was presented prior to exit.
2.b. For Resident #1 (R1), the facility staff failed to obtain a blood sugar check per physician's order.
A review of R1's clinical record revealed a nurse's note dated 12/13/24 (at 12:25 a.m.) that documented, Resident blood glucose recording HI (over 400), Rechecked several times. Insulin lispro 15 mls (milliliters) administered subcutaneously, and 18 units of glargine insulin administered. Glucose (blood sugar) continued to read high 30 min later. Message sent to NP (nurse practitioner), order to administer an additional 12 units of lispro insulin and recheck the glucose 2 hours later received.
A physician's order dated 12/13/24 documented, Recheck blood glucose at 0200 (2:00 a.m.) A review of R1's December 2024 medication administration record revealed the resident's blood sugar was not re-checked on 12/13/24 until 3:59 a.m.
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that if the nurse practitioner orders to re-check a resident's blood sugar at a certain time then the nurse should re-check the resident's blood sugar when the nurse practitioner says to re-check the blood sugar.
On 4/2/25 at 2:23 p.m., an interview was conducted with RN (registered nurse) #3 (the nurse who documented the above note). RN #3 stated her shift ended at 11:30 p.m. so she had to give report to the on-coming nurse and go home.
On 4/2/25 at 3:23 p.m., an interview was conducted with LPN #9 (the nurse who signed off re-checking R1's blood sugar at 3:59 a.m.) LPN #9 stated she did not remember R1.
On 4/2/25 at 4:09 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, Insulin Administration documented, Check blood glucose per physician order .
No further information was presented prior to exit.
3. For Resident #4 (R4), the facility staff failed to administer multiple medications per physician's orders.
A review of R4's clinical record revealed the following physician's orders:
12/3/24-Basaglar KwikPen Solution Pen-injector 100 unit/ml (milliliters) (Insulin Glargine). Inject 75 unit subcutaneously at bedtime for diabetes.
12/3/24-Gabapentin 100 mg (milligrams). Give one capsule by mouth three times a day for pain.
12/5/24-Trazodone 100 mg. Give one tablet by mouth at bedtime for insomnia related to major depressive disorder.
R4's December 2024 MAR (medication administration record) revealed the same physician's orders. Further review of R4's December 2024 MAR failed to reveal Basaglar was administered on 12/18/24 and 12/24/24, Gabapentin was administered on 12/24/24 at 9:00 p.m., and Trazodone was administered on 12/24/24, (as evidenced by blank spaces on the MAR).
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that if a medication is not available for administration, then nurses should check the Omnicell (a machine containing various medications), and if the medication is available in the Omnicell, nurses should obtain the medication and administer it.
A review of the Omnicell list revealed insulin glargine 100 unit/1ml, Gabapentin 100mg capsules, and Trazodone 50 mg tablets was available in the Omnicell.
On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
No further information was presented prior to exit.
Based on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide care and services to maintain a resident's highest level of well-being for five of 17 residents in the survey sample, Residents #3, #1, #4, #9 and #15.
The findings include:
1. For Resident #3 (R3), the facility staff failed to administer medications as ordered for bowel prep prior to a colonoscopy appointment which were available in the facility in house stock resulting in the procedure being rescheduled and delayed.
The physician orders for R3 documented in part,
- May use OTC meds from house stock per facility policy. Order Date: 5/18/2024.
- Patient has appt October 15th for colonoscopy, patient should have bowel prep on the 13th and 14th of October and also be on clear liquid diet on those days. patient, supervisor and relief nurse all notified. one time only until 10/15/2024 23:59. Order Date: 10/02/2024. Start Date: 10/13/2024.
- Mix the entire bottle of Miralax powder (238 grams) with the Gatorade or 64 ounces of lemonade in a large container. Shake to dissolve and place in refrigerator one time only for colonoscopy prep until 10/14/2024 23:59. Order Date: 9/17/2024. Start Date: 10/14/2024.
- Gavilax Powder (Polyethylene Glycol 3350) Give 238 gram by mouth every shift for colonoscopy prep for 1 Day drink 8 oz (1 cup) of prep solution every 15 minutes until you have finished half of the prep solution. Order Date: 09/17/2024. Start Date: 10/14/2024.
- Gavilax Powder (Polyethylene Glycol 3350) Give 238 gram by mouth every shift for colonoscopy prep for 1 Day drink 8 oz (1 cup) of prep solution every 15 minutes until you have finished half of the prep solution. Order Date: 09/17/2024. Start Date: 10/15/2024.
Review of the facility house stock medication list revised 12/13/2023 documented Polyethylene glycol 3350 (Miralax/clearlax) stocked in house at the facility.
The eMAR (electronic medication administration record) for R3 documented the Miralax powder not mixed on 10/14/24 and not administered on 10/14/24 night shift. The eMAR documented Other/See Nurses Notes .
The nurses notes for R3 documented in part,
- 9/11/2024 13:57 (1:57 p.m.) Nursing note. Note Text: Resident made aware of future appts scheduled for Oct. 15, 16, and 17. Copies of the appt given to the resident. Also, instructions for the colonoscopy were given to the resident to be aware.
- 10/14/2024 15:53 (3:53 p.m.) Administration note. Note Text: Mix the entire bottle of Miralax powder (238 grams) with the Gatorade or 64 ounces of lemonade in a large container. Shake to dissolve and place in refrigerator. one time only for colonoscopy prep until 10/14/2024 23:59. reorder. MD (medical doctor) made aware.
- 10/15/2024 00:09 (12:09 a.m.) Administration note. Note Text: Gavilax Powder Give 238 gram by mouth every shift for colonoscopy prep for 1 Day drink 8 oz (1 cup) of prep solution every 15 minutes until you have finished half of the prep solution. medication did not arrive per previous nurse report, resident told 3-11 nurse his appointment was canceled.
- 10/29/2024 15:03 (3:03 p.m.) Nursing note. Note Text: Writer spoke to the scheduling department with [Name of hospital] regarding rescheduling resident Colonoscopy. Per office no available appts for the rest of this year. Once new schedule opens up for Jan/2025 someone will contact the facility with appt date/time. [phone number].
On 4/2/25 at 6:38 a.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that she had received report from the evening shift nurse on 10/14/24 at R3's bowel prep had not arrived from the pharmacy, and it had not been started as scheduled. She stated that she spoke with R3 who told her the appointment had been canceled because the medication had not been sent from the pharmacy, and he was supposed to have started it the evening prior to her shift.
On 4/2/25 at 11:20 a.m., an interview was conducted with LPN #7 who stated that medication was evidenced by signing it off on eMAR. She stated that if the medication was not available the nurse should notify the provider that the medication was not available and call the pharmacy. She stated that if it was a colonoscopy prep the pharmacy may be able to send the medication over stat if they did not have the medication in the stock medications. LPN #7 stated that normally the medication could be sent over in a couple of hours or the physician may change it to something else so the procedure would not have to be rescheduled or canceled.
On 4/2/25 at 11:52 a.m., an interview was conducted with LPN #8 who stated that all the nurses should be aware of the in-house medications and how to access them. She stated that Miralax was stocked in the medication rooms and each nurse had access to the room with their medication cart keys.
The facility policy Medication and Treatment Orders dated 10/1/21 documented in part, .The facility has sufficient staff and a medication distribution system to ensure safe administration of medication without unnecessary interruptions . If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit .
On 4/2/25 at 4:08 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were made aware of the concern.
No further information was provided prior to exit.
4.The facility staff failed to provide care and services to promote a resident's highest level of wellbeing by providing PICC/midline care for R9.
Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences.
A review of the physician's order dated 11/21/24 revealed, Change PICC/Midline dressing q7days every day
shift every 7 day(s). Physician's order dated 3/10/25 revealed, DC PICC one time only for ABX COMPLETED.
A review of the progress note dated 3/2/25 at 10:36 PM revealed, Around 1900 patient called me in the room upset yelling and saying her line is contaminated, and it can't be used that I need to hurry up and find another kit to replace it. I was unsuccessful. I told her that I could not find another kit.
A review of the progress note dated 3/10/25 at 6:30 PM revealed, Received resident lying in bed on left side with eyes open. Resident informed that I would be removing her PICC line from her right upper arm. Dressing removed, PICC site cleansed, PICC line removed without difficulty. Catheter tip intact and measures 20cm. Resident denies pain or distress, tolerated well. Pressure dressing applied. Resident encouraged to notify charge nurse if site begins to bleed or is painful. Resident stated understanding.
An interview was conducted on 4/3/25 at 11:20 AM with LPN (licensed practical nurse) #7. When asked where evidence of PICC/Midline dressing change would be found, LPN #7 stated, it is either on the MAR or TAR. When asked if there is no documentation of the dressing changes, is there evidence of dressing changes being made, LPN #7 state, no, there is not evidence that it was done.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
The facility provided no policy regarding PICC/midline care.
No further information was provided prior to exit.
5. The facility staff failed to provide care and services to promote a resident's highest level of wellbeing by making GI (gastrointestinal) appointment for R15
Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode.
A review of the physician order dated 12/27/24 reveals, Appt with GI Date:12/30/24 Time: 12:30pm Pick up: 12:00pm Return ride.
No evidence of R15 going out to GI appointment in progress notes or elsewhere in the medical record.
An interview was conducted on 4/1/25 at 8:15 AM with R15. When asked if she had been out to any physician appointments, R15 stated, not that I remember.
A request was made for evidence of R15's physician appointment and transportation.
An 4/2/25 at 10:55 AM ASM #2 stated, I called the doctor's office tor R15, about the December 30, 2024, appointment. They did not have any appointment on their book for this resident. When asked if that indicated that the appointment was not made for this resident, ASM #2 stated, yes, it would seem that the appointment had not been made.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
Facility provided no policy related to appointments.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 care and services for a Foley urinary catheter (1) for one of 17 residents in the s...
Read full inspector narrative →
Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a Foley urinary catheter (1) for one of 17 residents in the survey sample, Resident #1.
The findings include:
For Resident #1 (R1), the facility staff failed to provide Foley catheter care during multiple shifts.
R1's diagnoses included but were not limited to neuromuscular dysfunction of the bladder. A review of R1's clinical record revealed a physician's order dated 4/30/24 for catheter care every shift and as needed. A review of R1's TARs (treatment administration records) for September 2024 through November 2024 revealed the same physician's order. Further review of the TARs failed to reveal catheter care was provided on the following dates (as evidenced by blank spaces on the TARs):
9/24/24 during day shift.
9/27/24 during night shift.
9/28/24 during night shift.
10/9/24 during day, evening, and night shifts.
10/18/24 during night shift.
10/19/24 during evening shift.
11/13/24 during day shift.
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated catheter care should be done at least once a shift and consists of cleaning around the catheter with soap and water, and emptying the catheter bag as often as needed. LPN #7 stated nurses evidence that catheter care was provided by signing it off on the TAR.
On 4/2/25 at 4:09 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, Urinary Catheter Care documented, Infection Control: 2. Maintain clean technique when handling or manipulating the drainage system .Routine hygiene (e.g. cleansing of the meatal surface during daily bathing or showering) is appropriate .d. Empty the collection bag at least every eight (8) hours .Documentation- The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given .
No further information was presented prior to exit.
Reference:
(1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**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 respiratory...
Read full inspector narrative →
**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 respiratory care and services for two of 17 residents in the survey sample, Residents #4 and #9.
The findings include:
1. For Resident #4 (R4), the facility staff failed to administer oxygen per physician's order on multiple shifts.
R4's diagnoses included but were not limited to chronic obstructive pulmonary disease (lung disease). A review of R4's clinical record revealed a physician's order dated 12/5/24 for continuous oxygen at two liters per minute every shift. A review of R4's December 2024 TAR (treatment administration record) revealed the same physician's order. Further review of R4's December 2024 TAR failed to reveal oxygen was administered on the following dates (as evidenced by blank spaces on the TAR):
12/14/24 during night shift.
12/16/24 during day shift.
12/19/24 during day shift.
12/24/24 during evening shift.
On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated nurses should ensure residents are administered oxygen per physician's orders and should monitor residents' oxygen levels every shift. LPN #7 stated nurses evidence this care is provided by signing it off on the TAR.
On 4/2/25 at 4:09 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, Oxygen Administration documented, Preparation- 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Documentation: After completing oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed .
No further information was presented prior to exit.
2. The facility staff failed to provide respiratory therapy per physician orders for R9.
Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences.
A review of the physician orders dated 10/8/24 revealed, Oxygen 4 liters via NC (continuous) every shift may
need more O2 with exertion.
A review of the March 2025 TAR (treatment administration record) revealed, missing documentation of oxygen administration on following shifts: day shift-3/2, 3/7, 3/19, 3/21; evening shift-3/2, 3/3, ¾, 3/11, 3/16, 3/18, 3/29 and night shift-3/18, 3/25.
An interview was conducted on 4/2/25 at 12:20 PM with LPN (licensed practical nurse) #8. When asked where oxygen administration per orders is evidenced, LPN #8 stated, it is documented on the TAR. When asked if the documentation is missing, is there evidence of administration, LPN #8 stated, no, there is no evidence.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Oxygen Administration policy revealed, Documentation-after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: the rate of oxygen flow, route and rationale.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence physician's response to the pharmacist's recommendations on the Medication Regimen Review (MRR) for one of 17 residents in the survey sample, R9.
The findings include:
The facility staff failed to ensure the physician's response to the pharmacist's recommendations for the 10/25/24 and 2/28/25 MRR for R9.
Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences.
A review of the 10/25/24 MRR recommendation revealed, This resident has been taking antibiotic Fluconazole and Ketoconazole since 10/24. While sometimes indicated, it is recommended that all antibiotics given for a period of more than 30 days be evaluated for appropriateness and duration. No physician response found.
A review of the 2/28/25 MRR recommendation revealed, This resident has been taking Protonix 40 mg QD since 10/2024 without a dose reduction. Please consider a trial reduction to 20 mg QD. No physician response found.
An interview was conducted on 4/2/25 at 10:00 AM with ASM (administrative staff member) #7, the nurse practitioner. When asked the process for reviewing the MRR, ASM #7 stated, we review the recommendations and then respond to them. When asked where this is documented, ASM #7 stated on the MRR form.
On 4/3/25 at 9:00 AM, ASM #1, the administrator, stated, there is nothing else to provide.
On 4/2/25 at 4:00 PM, ASM #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Medication Regimen Review policy revealed, Recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon recommendation or rejects and provides an explanation for disagreeing.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.The facility staff failed to provide honor dietary and allergy preferences by serving resident products with gluten.
Resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.The facility staff failed to provide honor dietary and allergy preferences by serving resident products with gluten.
Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences.
A review of the physician's order dated 10/10/24 revealed, Consistent Carbohydrate (CCD/CCHO) diet Regular
texture, Regular/Thin consistency, ALLERGIES: Blueberries, Corn, Fish, Potato / Double protein, double vegetable with meals.
A review of the 10/17/24 nutrition assessment revealed, Needs are increased d/t morbid obese BMI. RD spoke w/ resident on 10/16 to review diet, food preferences, weight, and PO intakes. Resident requesting double protein and double vegetable w/ meals to increase satiety. Order started and tray card updated accordingly. RD will continue to monitor and follow-up PRN.
An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked about her dietary preferences, R9 stated, there are many allergies, I cannot have gluten, and I am Jewish and follow Jewish dietary guideline. They do not seem to understand that and have told me I need to prove to them that I need a gluten free diet and do not understand my Jewish dietary needs.
A review of R9's 3/31 lunch meal ticket revealed, ALLERGIES: Blueberries, Corn, Fish, Potato / Double protein, double vegetable with meals. Dislike pancakes, French toast, bread. On her lunch tray were 2 bowls of chicken noodle soup. R9 stated to CNA (certified nursing assistant) #3, I cannot each that soup with the noodles in it. CNA #3 stated, I will go bring you a new tray. CNA #3 came back with new tray with 2 bowls of chicken noodle soup. R9 said, never mind, I will eat something I have here.
An interview was conducted on 4/1/25 at 10:00 AM with OSM (other staff member) #3, the director of dietary services. When asked the process for determining a resident's food preferences, OSM #3 stated, the registered dietician and I visit with the resident when they are admitted , the nurse gets the diet order, and we enter it. The residents are told the menus and alternatives for each meal. Food allergies come across electronically and by resident interview. Dining Manager system- prints out meal tickets for residents, allergies and religious dietary restrictions should be on the meal tickets. Dislikes are printed separately. If the resident has an allergy to or Dislike of then we find something else to substitute. When asked if a resident is not to have gluten or is to have double protein are two bowls of chicken noodle soup meeting these requirements and are preferences being honored, OSM #3 stated, no, preferences not being met.
On 4/2/25 at 4:00 PM during end of day conference, when told of concern regarding R9's food preferences being honored, ASM #1 the administrator, interrupted and stated, how do you know she is Jewish? Do you know she is Jewish? Did she tell you she was Jewish. We offered to send her to the hospital to have the test for Celiac (gluten) and she said no. When asked if it mattered whether she was Jewish or refused the Celiac test in order to honor her food preferences, ASM #1 stated, no.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Resident's Right to Make Personal Dietary, Food and Meal Choices policy revealed, The facility recognizes the resident's/ resident representative's right to make personal dietary, food and meal choices. The facility also recognizes the right of the resident to receive services in the facility with reasonable accommodations of individual needs and religious, cultural and ethnic preferences.
No further information was provided prior to exit.
2. The facility staff failed to provide honor dietary preferences by serving resident eggs.
Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode.
A review of the physician order dated 9/11/24 reveals, Regular diet Regular texture, Regular/Thin consistency, No Sausage Please Give Bacon. Yogurt QD in between meals for diet.
A review of the nutritional risk assessment dated [DATE] revealed, Meal intakes 50-100% (~95%) + yogurt 1x/day = 2258kcal, 91g protein Estimated needs are skewed high r/t morbid obese BMI. Resident continues w/ good meal intakes. Estimated needs are likely being met. No s/s of dehydration noted. No sausage, give bacon. See tray card. No known food allergies. No information in 'special ethnic or cultural needs' or 'religious preferences' sections.
An interview was conducted on 4/1/25 at 5:45 AM with R15. R15 stated, they do not serve me the food that I like.
On 4/1/25 at 8:10 AM observed R15 breakfast tray and meal ticket. On tray were eggs, meal ticket-dislike eggs.
An interview was conducted on 4/1/25 at 10:00 AM with OSM (other staff member) #3, the director of dietary services. When asked the process for determining a resident's food preferences, OSM #3 stated, the registered dietician and I visit with the resident when they are admitted , the nurse gets the diet order, and we enter it. The residents are told the menus and alternatives for each meal. Food allergies come across electronically and by resident interview. Dining Manager system- prints out meal tickets for residents, allergies and religious dietary restrictions should be on the meal tickets. Dislikes are printed separately. If the resident has an allergy to or Dislike of then we find something else to substitute. When asked if a resident is not to have eggs and they are served eggs, are preferences being honored, OSM #3 stated, no, preferences not being met.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Resident's Right to Make Personal Dietary, Food and Meal Choices policy revealed, The facility recognizes the resident's/ resident representative's right to make personal dietary, food and meal choices. The facility also recognizes the right of the resident to receive services in the facility with reasonable accommodations of individual needs and religious, cultural and ethnic preferences.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks during the day and at bedtime for two of 17 residents in the survey sample, R11 and R15.
The findings include:
1. The facility staff failed to provide snacks during the day and at bedtime for Resident #11.
Resident #11 (R11) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Parkinson's Disease, convulsions and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 3/31/25 revealed, FOCUS: The resident is frequently incontinent of bladder and bowels. INTERVENTIONS: Provide substantial/maximal assistance with toileting.
Observations in the nourishment Unit 1 and Unit 2 on 3/31/25 at 8:20 AM, 11:15 AM, 3:30 PM and 4/1/25 at 6:10 AM revealed, no snacks available including milk, applesauce, ice cream, crackers, yogurt, peanut butter with exception of 2 milk and 2 yogurts found on Unit 2 at 8:25 AM on 3/31/25.
Facility census was 120 on entrance 3/31/25.
An interview was conducted on 3/31/25 at 10:35 AM when R11, when asked if he received snacks during the day and at bedtime, R11 stated, no, there are no snacks. We can buy some, but they do not give us any.
An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked if he had snacks for residents, CNA #3 stated, no there are no snacks for the residents on day or evening shift.
An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. When asked if she has snacks to provide to residents, CNA #4 stated, the kitchen sends down some PBJ (peanut butter jelly) and cheese sandwiches for the diabetic residents. There are no other snacks for the residents, no crackers, applesauce or milk.
An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had snacks, they need for the residents. CNA #7 stated, we have no snacks for the residents. Opened a cabinet door in nourishment room and stated, look at this, took out 12-ounce jar of peanut butter and opened it. Approximately one teaspoon of peanut butter in the bottom. CNA #7 stated, what do you do with this amount, and we have no crackers.
An interview was conducted on 4/1/25 at 10:15 AM with OSM (other staff member) #3, the Director of Dietary Services. When asked what snacks are provided to the residents, OSM #3 stated we send out snack for bedtime, extra sandwiches, PBJ. We offer PBJ and grilled cheese at any time of the day. When asked if milk, applesauce, crackers are stocked for the residents during the day, OSM #3 stated, no, we have never had par levels for nourishment. I was not aware there was an issue.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Between Meal and Bedtime Snacks policy revealed, The purpose of this procedure is to provide the resident with adequate nutrition.
No further information was provided prior to exit.
2. The facility staff failed to provide snacks during the day and at bedtime Resident #15.
Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode.
Observations in the nourishment Unit 1 and Unit 2 on 3/31/25 at 8:20 AM, 11:15 AM, 3:30 PM and 4/1/25 at 6:10 AM revealed, no snacks available including milk, applesauce, ice cream, crackers, yogurt, peanut butter with exception of 2 milk and 2 yogurts found on Unit 2 at 8:25 AM on 3/31/25.
Facility census was 120 on entrance 3/31/25.
An interview was conducted on 4/1/25 at 5:45 AM with R15. R15 stated, there is no snacks for the residents. Nothing in between meals.
An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked if he had snacks for residents, CNA #3 stated, no there are no snacks for the residents on day or evening shift.
An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. When asked if she has snacks to provide to residents, CNA #4 stated, the kitchen sends down some PBJ (peanut butter jelly) and cheese sandwiches for the diabetic residents. There are no other snacks for the residents, no crackers, applesauce or milk.
An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had snacks, they need for the residents. CNA #7 stated, we have no snacks for the residents. Opened a cabinet door in nourishment room and stated, look at this, took out 12-ounce jar of peanut butter and opened it. Approximately one teaspoon of peanut butter in the bottom. CNA #7 stated, what do you do with this amount, and we have no crackers.
An interview was conducted on 4/1/25 at 10:15 AM with OSM (other staff member) #3, the Director of Dietary Services. When asked what snacks are provided to the residents, OSM #3 stated we send out snack for bedtime, extra sandwiches, PBJ. We offer PBJ and grilled cheese at any time of the day. When asked if milk, applesauce, crackers are stocked for the residents during the day, OSM #3 stated, no, we have never had par levels for nourishment. I was not aware there was an issue.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
A review of the facility's Between Meal and Bedtime Snacks policy revealed, The purpose of this procedure is to provide the resident with adequate nutrition.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0907
(Tag F0907)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide supplies, including urinals, gloves, cup tops for the for two of 17 residents in the survey sample, R11 and R15.
The findings include:
1. The facility staff failed to provide supplies, including urinals, gloves, cup tops for Resident #11.
Resident #11 (R11) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Parkinson's Disease, convulsions and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 3/31/25 revealed, FOCUS: The resident is frequently incontinent of bladder and bowels. INTERVENTIONS: Provide substantial/maximal assistance with toileting.
Observations in the supply/linen closets on Unit 1 and Unit 2 on 3/31/25 at 8:20 AM, 3:30 PM and 4/1/25 at 6:10 AM revealed, no urinals or gloves on 3/31 8:20 AM, at 3:30 PM there were 4 urinals and 2 boxes of gloves in each closet and on 4/1 at 6:10 AM there were 2 urinals and 2 boxes of gloves in each closet.
Facility census was 120 on entrance 3/31/25.
An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the supplies they need, CNA #1 stated, no, we run out of supplies. When asked what supplies, CNA #1 stated, sometimes urinals, adult briefs and gloves. We have to get gloves from different resident rooms at times or carry them in our pocket.
An interview was conducted on 3/31/25 at 3:25 PM with CNA #5, when asked if she has supplies that she needs for evening shift, CNA #5 stated, no, we are short with gloves, adult diapers and urinals. We did not have urinals and only a few gloves any over the weekend.
An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. CNA #4 approached CNA #5 and I in the linen/supply room on Unit 1 and asked CNA #5 if she had found any gloves. CNA #4 stated, in several rooms there are no gloves, are there any here. When asked if they are short of supplies, CNA #4 stated, yes, gloves, urinals, towels, washcloths and sheets.
An interview was conducted on 4/1/25 at 5:30 AM with CNA #6. When asked if night shift had any shortages of supplies, CNA #6 stated, we are okay last night with urinals but short on gloves.
An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had supplies, CNA #7 stated, sometimes we are short on gloves and urinals.
An interview was conducted on 4/1/25 at 10:57 AM with OSM (other staff member) #4, the central supply supervisor. When asked about the supply process for the facility, OSM #4 stated, the process for ordering supplies, is that the director of nursing goes through the system and orders it. I have only been in this role about 3 weeks. Usually diapers, gloves, wipes, are ordered. I come in everyday and see if we have it in the shed. Shipment came in yesterday; we did not receive any urinals in the order Friday, so they delivered it on Monday. I come to the floors and check the supply closets, if the nurses/aides tell me they need something, I go to shed and if we don't have it, come back in and talk with the DON or ADM to enter order. When ask what happens if there are zero of a needed item, like urinals or gloves, OSM #4 stated, we can do a rush order. Normally we order weekly. I work Monday through Friday. I typically stock Monday & Friday day shift. If they don't have something and I am not here, then they call me, but I try to make sure supplies are in central supply.
An interview was conducted on 4/2/25 at 6:00 AM with CNA #7. When asked if there were supply shortages during the night, CNA #7 stated, see these bottles of water, we are giving the residents bottles of water because we have no lids for their water cups.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
No policy regarding supplies was provided by the facility.
No further information was provided prior to exit.
2. The facility staff failed to provide supplies, including gloves, cup tops for Resident #15.
Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode.
Facility census was 120 on entrance 3/31/25.
An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the supplies they need, CNA #1 stated, no, we run out of supplies. When asked what supplies, CNA #1 stated, sometimes urinals, adult briefs and gloves. We have to get gloves from different resident rooms at times or carry them in our pocket.
An interview was conducted on 3/31/25 at 3:25 PM with CNA #5, when asked if she has supplies that she needs for evening shift, CNA #5 stated, no, we are short with gloves, adult diapers and urinals. We did not have urinals and only a few gloves any over the weekend.
An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. CNA #4 approached CNA #5 and I in the linen/supply room on Unit 1 and asked CNA #5 if she had found any gloves. CNA #4 stated, in several rooms there are no gloves, are there any here.
When asked if they are short of supplies, CNA #4 stated, yes, gloves, urinals, towels, washcloths and sheets.
An interview was conducted on 4/1/25 at 5:30 AM with CNA #6. When asked if night shift had any shortages of supplies, CNA #6 stated, we are okay last night with urinals but short on gloves.
An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had supplies, CNA #7 stated, sometimes we are short on gloves and urinals.
An interview was conducted on 4/1/25 at 5:45 AM with R15. When asked about supplies, R15 stated, they do not always have my size briefs.
An interview was conducted on 4/1/25 at 10:57 AM with OSM (other staff member) #4, the central supply supervisor. When asked about the supply process for the facility, OSM #4 stated, the process for ordering supplies, is that the director of nursing goes through the system and orders it. I have only been in this role about 3 weeks. Usually diapers, gloves, wipes, are ordered. I come in everyday and see if we have it in the shed. Shipment came in yesterday; we did not receive any urinals in the order Friday, so they delivered it on Monday. I come to the floors and check the supply closets, if the nurses/aides tell me they need something, I go to shed and if we don't have it, come back in and talk with the DON or ADM to enter order. When ask what happens if there are zero of a needed item, like urinals or gloves, OSM #4 stated, we can do a rush order. Normally we order weekly. I work Monday through Friday. I typically stock Monday & Friday day shift. If they don't have something and I am not here, then they call me, but I try to make sure supplies are in central supply.
An interview was conducted on 4/2/25 at 6:00 AM with CNA #7. When asked if there were supply shortages during the night, CNA #7 stated, see these bottles of water, we are giving the residents bottles of water because we have no lids for their water cups.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
No policy regarding supplies was provided by the facility.
No further information was provided prior to exit.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for the facility.
The findings inclu...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for the facility.
The findings include:
The facility staff failed to follow infection control practices for linen storage.
On 4/1/25 at approximately 5:50 AM, ASM (administrative staff member) #1, the administrator and this surveyor were making round of the unit linen closets to review levels. ASM #1 stated, we have more linen than this. They start bringing out the linen cart at 6:45 AM. ASM #1 took me to linen/EVS area and stated, there is more linen on those shelves. Packs of blankets, wrapped in plastic were on shelves next to one blanket and one sheet on open shelf next to environmental services cart and mops. When asked if the linen should be unwrapped next to the environmental services cart, ASM #1 stated, no, it should not be. When asked if it is an infection control issue to have unwrapped linen next to environmental services cart, ASM #1 stated, yes, it is.
On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings.
No policy was provided by the facility.
No further information was provided prior to exit.
Mar 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the fac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for three of 5 residents in the survey sample, R1, R2 and R3.
The findings include:
1. The facility staff failed to implement the comprehensive care plan for incontinence care for R1.
R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), HIV (human immunodeficiency virus) cancer and malnutrition.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/11/25, 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 MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing; dependent for toileting and supervision for eating.
A review of the comprehensive care plan dated 12/9/24 revealed, FOCUS: CONTINENCE: due to generalized
weakness, due to severe cognitive impairment, due to severe physical impairment. INTERVENTIONS: Provide substantial/maximal assistance with toileting. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed.
A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: December 2024-night shift: 12/1 and 12/29: January 2025-day shift: 1/5, 1/6, 1/7, and 1/8, evening shift: 1/1, 1/8 and 1/9; February 2025-day shift 2/16, evening shift-2/2, 2/16 and night shift 2/1.
An interview was conducted on 3/11/25 at 1:55 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, so the resident and the family can talk about needs and anything that the resident needs addressed. When asked if the interventions listed on the care plan are not evidenced, was the care plan implemented, LPN #1 stated, no.
On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns.
No further information was provided prior to exit.
2. The facility staff failed to implement the comprehensive care plan for incontinence care for R2.
R2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to colitis, DM (diabetes mellitus), hemiplegia and hemiparesis.
The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 2/7/25, 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 MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing; dependent for toileting and eating.
A review of the comprehensive care plan dated 12/2/24 revealed, FOCUS: CONTINENCE: the resident is frequently incontinent of bladder and bowels and is not a candidate for a toileting program, due to generalized weakness, due to severe physical impairment, due to stress incontinence. INTERVENTIONS: Check and change briefs frequently as needed. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed.
A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: January 2025-day shift: 1/3, 1/6, 1/11, 1/27, 1/28, 1/30; evening shift: 1/3, 1/6, 1/11, 1/12, 1/14, 1/19, 1/20, 1/24, 1/27 and night shift: 1/1, 1/25; February 2025- day shift: 2/10, 2/11, 2/16, 2/23; evening shift: 2/11, 2/15, 2/17 and night shift 2/1, 2/11, 2/22; March 2025-evening shift: 3/3, 3/9 and night shift 3/1.
An interview was conducted on 3/11/25 at 1:55 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, so the resident and the family can talk about needs and anything that the resident needs addressed. When asked if the interventions listed on the care plan are not evidenced, was the care plan implemented, LPN #1 stated, no.
On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns.
No further information was provided prior to exit.
3. The facility staff failed to implement the comprehensive care plan for incontinence care for R3.
R3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Rhabdomyolysis, DM (diabetes mellitus) and Spondylosis.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/26/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing/toileting and supervision for eating.
A review of the comprehensive care plan dated 10/3/24 revealed, FOCUS: The resident has bladder incontinence related to Physical limitations, BPH (benign prostatic hyperplasia). INTERVENTIONS: Clean peri-area with each incontinence episode. Physical assist with all ADLs.
A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: January 2025-day shift: 1/6, 1/7, 1/8, 1/9, 1/10; evening shift: 1/19, 1/23 and night shift: 1/1, Jan.4th, 1/5, 1/22, 1/23; February 2025- day shift: 2/2, 2/4, 2/14; evening shift: 2/17 and night shift 2/1, 2/3, 2/18, 2/24, 2/25; March 2025-evening shift: 3/3, 3/4 and night shift 3/2, March 4th, 3/5 and 3/9.
An interview was conducted on 3/11/25 at 1:55 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, so the resident and the family can talk about needs and anything that the resident needs addressed. When asked if the interventions listed on the care plan are not evidenced, was the care plan implemented, LPN #1 stated, no.
On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staf...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of five residents, R1, R2 and R3.
The findings include:
1.The facility staff failed to provide ADL (activities of daily living) specifically incontinence care for a dependent resident, R1.
R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), HIV (human immunodeficiency virus) cancer and malnutrition.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/11/25, 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 MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing; dependent for toileting and supervision for eating.
A review of the comprehensive care plan dated 12/9/24 revealed, FOCUS: CONTINENCE: due to generalized
weakness, due to severe cognitive impairment, due to severe physical impairment. INTERVENTIONS: Provide substantial/maximal assistance with toileting. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed.
A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: December 2024-night shift: 12/1 and 12/29: January 2025-day shift: 1/5, 1/6, 1/7, and 1/8, evening shift: 1/1, 1/8 and 1/9; February 2025-day shift 2/16, evening shift-2/2, 2/16 and night shift 2/1.
An interview was conducted on 3/11/25 at 10:55 AM with CNA (certified nursing assistant) #1. When asked the incontinence care process, CNA #1 stated, we round on the residents and provide incontinence care. When asked if there are time frames for incontinence care to be provided, CNA #1 stated, not that I know of. When asked where the care is documented, CNA #1 stated, on the ADL form.
An interview was conducted on 3/11/25 at 1:40 PM with CNA #2. When asked the incontinence care process, CNA #2 stated, incontinence care, when we are all here and staffed, I do it when I come in and then about 2 PM after lunch. We document on the ADL report, and we document everything. We would document something whether they are incontinent or continent.
On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns.
No further information was provided prior to exit.
2. The facility staff failed to provide ADL (activities of daily living) specifically incontinence care for a dependent resident, R2.
R2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to colitis, DM (diabetes mellitus), hemiplegia and hemiparesis.
The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 2/7/25, 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 MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing; dependent for toileting and eating.
A review of the comprehensive care plan dated 12/2/24 revealed, FOCUS: CONTINENCE: the resident is frequently incontinent of bladder and bowels and is not a candidate for a toileting program, due to generalized weakness, due to severe physical impairment, due to stress incontinence. INTERVENTIONS: Check and change briefs frequently as needed. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed.
A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: January 2025-day shift: 1/3, 1/6, 1/11, 1/27, 1/28, 1/30; evening shift: 1/3, 1/6, 1/11, 1/12, 1/14, 1/19, 1/20, 1/24, 1/27 and night shift: 1/1, 1/25; February 2025- day shift: 2/10, 2/11, 2/16, 2/23; evening shift: 2/11, 2/15, 2/17 and night shift 2/1, 2/11, 2/22; March 2025-evening shift: 3/3, 3/9 and night shift 3/1.
An interview was conducted on 3/11/25 at 10:55 AM with CNA (certified nursing assistant) #1. When asked the incontinence care process, CNA #1 stated, we round on the residents and provide incontinence care. When asked if there are time frames for incontinence care to be provided, CNA #1 stated, not that I know of. When asked where the care is documented, CNA #1 stated, on the ADL form.
An interview was conducted on 3/11/25 at 1:40 PM with CNA #2. When asked the incontinence care process, CNA #2 stated, incontinence care, when we are all here and staffed, I do it when I come in and then about 2 PM after lunch. We document on the ADL report, and we document everything. We would document something whether they are incontinent or continent.
On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns.
No further information was provided prior to exit.
3. The facility staff failed to provide ADL (activities of daily living) specifically incontinence care for a dependent resident, R3.
R3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Rhabdomyolysis, DM (diabetes mellitus) and Spondylosis.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/26/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing/toileting and supervision for eating.
A review of the comprehensive care plan dated 10/3/24 revealed, FOCUS: The resident has bladder incontinence related to Physical limitations, BPH (benign prostatic hyperplasia). INTERVENTIONS: Clean peri-area with each incontinence episode. Physical assist with all ADLs.
A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: January 2025-day shift: 1/6, 1/7, 1/8, 1/9, 1/10; evening shift: 1/19, 1/23 and night shift: 1/1, Jan.4th, 1/5, 1/22, 1/23; February 2025- day shift: 2/2, 2/4, 2/14; evening shift: 2/17 and night shift 2/1, 2/3, 2/18, 2/24, 2/25; March 2025-evening shift: 3/3, 3/4 and night shift 3/2, March 4th, 3/5 and 3/9.
An interview was conducted on 3/11/25 at 10:55 AM with CNA (certified nursing assistant) #1. When asked the incontinence care process, CNA #1 stated, we round on the residents and provide incontinence care. When asked if there are time frames for incontinence care to be provided, CNA #1 stated, not that I know of. When asked where the care is documented, CNA #1 stated, on the ADL form.
An interview was conducted on 3/11/25 at 1:40 PM with CNA #2. When asked the incontinence care process, CNA #2 stated, incontinence care, when we are all here and staffed, I do it when I come in and then about 2 PM after lunch. We document on the ADL report, and we document everything. We would document something whether they are incontinent or continent.
On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns.
No further information was provided prior to exit.
Jul 2024
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 provide incontinence care for three of fifteen residents in the surve...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide incontinence care for three of fifteen residents in the survey sample, Residents #2, #5 and #6.
The findings include:
1. The facility staff failed to provide incontinence care for a dependent resident for Resident # 2.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R2 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R2 was coded as being dependent for toileting hygiene.
A review of R2's clinical record revealed a facility document, Documentation Survey Report V2 for March 2024 that includes documentation for ADL- Toilet Use, it revealed there were shifts where no incontinence care was provided.
A review of R2's care plan, revealed in part: Encourage with BR (bathroom) as able and allowed to facilitate BM (bowel movement)/ resident may show increase movement in bed when toileting is needed .If resident is awakens during the night encourage toileting .The resident has bowel incontinence. The resident will continue to be continent during daytime through review date. Observe pattern on incontinence, and initiate toileting schedule if indicated. Provide peri-care after each incontinent episode.
On 7/31/24 at 1:01 p.m., CNA (certified nursing assistant) #1 was interviewed. CNA #1 stated that for incontinence care, the CNAs should perform care if resident needs and to also check on the resident every 2 hours and see if they need care. She also stated that they document incontinence in resident 's clinical record. She also mentioned that if the resident refuses incontinence care they would let a nurse know and the nurse would educate the patient and document in the clinical record. She also mentioned that incontinence care should be given even if the resident has a guest. She adds that when you provide the care ask the family to step out, provide privacy and document it.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services, were made aware of above concerns.
The facility policy titled, Urinary Continence and Incontinence-Assessment and Management documented, The staff and practitioner will appropriately screen for, and manage, individuals with urinary and/ or fecal incontinence .The physician/practitioner and staff will provide appropriate services and treatment to help residents restore or improve bladder/bowel function and prevent infections to the extent possible .Facility staff will provide and/or assist the resident with incontinence care as needed .Facility staff will provide peri-care timely and will apple barrier creams to promote good skin integrity.
No further information was provided prior to exit.
2. The facility staff failed to provide incontinence care for a dependent resident for Resident #5.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R5 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). R5 was coded as being dependent for toileting hygiene.
A review of R5's clinical record revealed a facility document, Documentation Survey Report V2 for July 2024 that includes documentation for ADL- Toilet Use, it revealed there were shifts where no incontinence care was provided.
On 7/31/24 at 1:01 p.m., CNA (certified nursing assistant) #1 was interviewed. CNA #1 stated that for incontinence care, the CNAs should perform care if resident needs and to also check on the resident every 2 hours and see if they need care. She also stated that they document incontinence in resident 's clinical record. She also mentioned that if the resident refuses incontinence care they would let a nurse know and the nurse would educate the patient and document in the clinical record. She also mentioned that incontinence care should be given even if the resident has a guest. She adds that when you provide the care ask the family to step out, provide privacy and document it.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services, were made aware of above concerns.
The facility policy titled, Urinary Continence and Incontinence-Assessment and Management documented, The staff and practitioner will appropriately screen for, and manage, individuals with urinary and/ or fecal incontinence .The physician/practitioner and staff will provide appropriate services and treatment to help residents restore or improve bladder/bowel function and prevent infections to the extent possible .Facility staff will provide and/or assist the resident with incontinence care as needed .Facility staff will provide peri-care timely and will apple barrier creams to promote good skin integrity.
No further information was provided prior to exit.
3. The facility staff failed to provide incontinence care for a dependent resident for Resident # 6.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R6 was coded as being dependent for toileting hygiene.
A review of R6's clinical record revealed a facility document, Documentation Survey Report V2 for July 2024 that includes documentation for ADL- Toilet Use, it revealed there were shifts where no incontinence care was provided.
A review of R6's care plan, revealed in part: Encourage resident with toileting after supper and before HS (hour of sleep) .Encourage toileting after meals as allowed .The resident has bowel incontinence. The resident will be continent during daytime through the review date. Observe pattern of incontinence, and initiate toileting schedule if indicated. Provide peri-care after each incontinent episode.
On 7/31/24 at 1:01 p.m., CNA (certified nursing assistant) #1 was interviewed. CNA #1 stated that for incontinence care, the CNAs should perform care if resident needs and to also check on the resident every 2 hours and see if they need care. She also stated that they document incontinence in resident 's clinical record. She also mentioned that if the resident refuses incontinence care they would let a nurse know and the nurse would educate the patient and document in the clinical record. She also mentioned that incontinence care should be given even if the resident has a guest. She adds that when you provide the care ask the family to step out, provide privacy and document it.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services, were made aware of above concerns.
The facility policy titled, Urinary Continence and Incontinence-Assessment and Management documented, The staff and practitioner will appropriately screen for, and manage, individuals with urinary and/ or fecal incontinence .The physician/practitioner and staff will provide appropriate services and treatment to help residents restore or improve bladder/bowel function and prevent infections to the extent possible .Facility staff will provide and/or assist the resident with incontinence care as needed .Facility staff will provide peri-care timely and will apple barrier creams to promote good skin integrity.
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 F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services for a colostomy for one of 15 residents in ...
Read full inspector narrative →
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services for a colostomy for one of 15 residents in the survey sample, Resident #4.
The findings include:
For Resident #4 (R4), the facility staff failed to provide colostomy (1) care during shifts on 3/8-3/11/24, 3/17/24, 3/26/24, 3/28/24, 3/29/24, 3/31/24, 4/12/24 and 5/3/24.
On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/23/24, the resident was assessed as having an ostomy.
The physician orders for R4 documented in part, Colostomy Care as needed AND every shift On hold from 02/01/2024 23:13 to 02/03/2024 23:12. Order Date: 01/03/2024.
Review of the eTARs (electronic treatment administration records) for R4 dated 3/1-3/31/24, 4/1- 4/30/24 and 5/1-5/31/24 failed to evidence colostomy care provided during shifts on 3/8-3/11/24, 3/17/24, 3/26/24, 3/28/24, 3/29/24, 3/31/24, 4/12/24 and 5/3/24.
The comprehensive care plan for R4 documented in part, [Name of R4] has an alteration in gastro-intestinal status r/t (related to) Colostomy. Date Initiated: 10/26/2023. Revision on: 06/01/2024. Under Interventions it documented in part, Provide colostomy care Q (every) shift and PRN (as needed). Date Initiated: 10/26/2023. Revision on: 06/01/2024.
On 7/31/24 at 12:57 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that they worked with R4 at the facility. She stated that the CNA staff emptied the colostomy bags and burped the bag to let gas out. She stated that the nurses changed the bags and evidenced the care by charting it in the medical record.
On 7/31/24 at 1:52 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that colostomy sites were assessed daily and care was provided every shift when they worked.
The facility policy Colostomy/Ileostomy Care, undated, documented in part, .Colostomy and ileostomy care will be provided by a licensed nurse and as ordered by the physician/practitioner .
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing and infection preventionist and ASM #3, the regional director of clinical services were made aware of the findings.
No further information was provided prior to exit.
Reference:
(1) Colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. This information was obtained from the website: https://medlineplus.gov/ency/article/002942.htm
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review and facility document review, it was determined that staff failed to provide feeding assistance for one of 15 residents, Resident #2 (R2).
The findings...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined that staff failed to provide feeding assistance for one of 15 residents, Resident #2 (R2).
The findings include:
The facility staff failed to provide feeding assistance for Resident #2 on March 23, 2024.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R2 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R2 was coded as being partial/moderate assistance for eating.
A review of R2's clinical record revealed a facility document, Documentation Survey Report V2 for March 2024 that includes documentation for ADL- Eating and nutrition revealed resident did not receive feeding assistance or eat on March 23, 2024.
A review of R2's physician orders dated 3/18/24 revealed, Mechanical Soft texture, Regular/Thin consistency, Diet: Mech Soft Liquids Thin for diet.
A review of R2's care plan, revealed in part: Resident is at risk for potential nutritional problems r/t (related to) new admission and facility adjustment, Poor PO intake, Mechanically altered diet, hospice .Maintain stable weight 3-5# through next review .Diet as ordered.
On 7/31/24 at 11:36 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated that CNA's especially agency CNA ' s will know if a resident requires feeding assistance when they get report on them or during morning report. CNA #1 also stated that they document if a resident eats, how much they eat and if they need assistance in the electronic clinical record. CNA#1 also added that if a resident refuses to eat they tell the nurse, and the nurse will document that.
On 7/31/24 at 1:53 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated that R2 did not have any issues with eating when she cared for them. LPN#1 stated that if there were any concerns there were probably from another shift. She also stated that she would feed the resident herself if the family was not there. LPN#1 added that R2's family were concerned about R2 not getting enough food. LPN #1 added that R2 was a slow eater and that she did not do well if she was rushed, and she often educated staff that she was someone that took longer and to make sure that they had ample time when doing that task.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services, were made aware of above concerns.
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 F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide complete dialysis care and services for one of 15 residents i...
Read full inspector narrative →
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide complete dialysis care and services for one of 15 residents in the survey sample, Resident #3.
The findings include:
For Resident #3 (R3), the facility staff failed to monitor the dialysis AV (arterio-venous) fistula (1) for function on 4/12-4/13/24, 5/30/24, 6/1-6-4/24 and 6/6/24.
The physician orders for R3 documented in part, Assess Dialysis Fistula/Graft (left) for Thrill and Bruit Daily and signs and symptoms of infection. every shift. Order Date: 04/15/2024.
Review of the eTARs (electronic treatment administration records) for R3 dated 4/1/24-4/30/24, 5/1/24-5/31/24 and 6/1/24-6/30/24 failed to evidence assessment of the dialysis fistula on 4/12-4/13/24, 5/30/24, 6/1-6-4/24 and 6/6/24.
The comprehensive care plan for R3 documented in part, The resident has ESRD (end stage renal disease) (2) and receives {Hemo/Peritoneal} dialysis . Date Initiated: 06/06/2024. Revision on: 06/07/2024 . Under Interventions it documented in part, .Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols .
On 7/31/24 at 1:52 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they worked with R3 at the facility. She stated that the staff should monitor a resident with a dialysis fistula each shift and they should check the site for bruit and thrill, look for any bleeding or signs of infection. She stated that this was evidenced by documentation in the clinical record.
The facility policy, Hemodialysis Access Care, undated, documented in part, .Care of AVFs (arterio-venous fistula) and AVGs (arterio-venous graft). 1. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 2. To prevent infection and/or clotting: .3. Check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing routine care and at regular intervals . 6. Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access . It further documented, .Documentation. The facility nurse will monitor and document every shift for: 1. Type of access. 2. Presence of bruit and thrill for AVG and AVG [sic]. 3. Signs and symptoms of infection. 4. Condition of dressing and interventions completed if needed. 5. Bleeding and interventions completed if needed.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing and infection preventionist and ASM #3, the regional director of clinical services were made aware of the findings.
No further information was provided prior to exit.
Reference:
(1) AV (arterio-venous) fistula: A vascular access is an opening made in your skin and blood vessel during a short operation. When you have dialysis, your blood flows out of the access into the hemodialysis machine. After your blood is filtered in the machine, it flows back through the access into your body. There are 3 main types of vascular accesses for hemodialysis. These are described as follows. Fistula: An artery in your forearm or upper arm is sewn to a vein nearby. This allows needles to be inserted into the vein for dialysis treatment. A fistula takes from 4 to 6 weeks to heal and mature before it is ready to use. Graft: An artery and a vein in your arm are joined by a U-shaped plastic tube under the skin. Needles are inserted into the graft when you have a dialysis. A graft can be ready to use in 2 to 4 weeks. Central venous catheter: A soft plastic tube (catheter) is tunneled under your skin and placed in a vein in your neck, chest, or groin. From there, the tubing goes into a central vein that leads to your heart. A central venous catheter is ready to use right away. It is usually used only for a few weeks or months . This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000591.htm
(2) end-stage kidney disease
The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
4. The facility staff failed to implement the comprehensive care plan regarding incontinence care for Resident #2.
On the most recent MDS (minimum data set), an admission assessment with an ARD (asses...
Read full inspector narrative →
4. The facility staff failed to implement the comprehensive care plan regarding incontinence care for Resident #2.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R2 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R2 was coded as being dependent for toileting hygiene.
A review of R2's clinical record revealed a facility document, Documentation Survey Report V2 for March 2024 that includes documentation for ADL- Toilet Use, it revealed there were shifts where no incontinence care was provided.
A review of R2's care plan, revealed in part: Encourage with BR (bathroom) as able and allowed to facilitate BM (bowel movement)/ resident may show increase movement in bed when toileting is needed .If resident is awakens during the night encourage toileting .The resident has bowel incontinence. The resident will continue to be continent during daytime through review date. Observe pattern on incontinence, and initiate toileting schedule if indicated. Provide peri-care after each incontinent episode.
On 7/31/24 at 1:52 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to alert all staff involved in the residents' care what the goals were for that person and what the recommendations were for the safety of that resident. She stated that the care plan was used to track any improvement or decline in condition, and it was to be implemented because it was part of the process to care for the resident.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services, were made aware of above concerns.
No further information was provided prior to exit.
5.The facility staff failed to implement the comprehensive care plan for Resident # 6.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R6 was coded as being dependent for toileting hygiene.
A review of R6's clinical record revealed a facility document, Documentation Survey Report V2 for July 2024 that includes documentation for ADL- Toilet Use, it revealed there were shifts where no incontinence care was provided.
A review of R6's care plan, revealed in part: Encourage resident with toileting after supper and before HS (hour of sleep) .Encourage toileting after meals as allowed .The resident has bowel incontinence. The resident will be continent during daytime through the review date. Observe pattern of incontinence, and initiate toileting schedule if indicated. Provide peri-care after each incontinent episode.
On 7/31/24 at 1:52 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to alert all staff involved in the residents' care what the goals were for that person and what the recommendations were for the safety of that resident. She stated that the care plan was used to track any improvement or decline in condition, and it was to be implemented because it was part of the process to care for the resident.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services, were made aware of above concerns.
No further information was provided prior to exit.
Based on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 15 residents in the survey sample, Residents #8, #3, #4, #2 and #6.
The findings include:
1. For Resident #8 (R8), the facility staff failed to implement the comprehensive care plan to maintain contact precautions for a diagnosis of C-diff (clostridium difficile) (1).
On 7/30/24 at approximately 10:22 a.m., an observation was made of the facility. Observation of R8's room revealed a sign posted outside of the door with stop signs on the corners of the notice. The signage documented Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.
On 7/30/24 at 12:45 p.m., a facility staff member was observed entering R8's room carrying a lunch tray. The staff member was observed wearing a surgical mask with no other PPE (personal protective equipment). The staff member was observed touching contents of R8's overbed table to make room for the lunch tray. The staff member was observed using alcohol based hand sanitizer prior to exit of R8's room.
On 7/30/24 at 4:09 p.m., a facility staff member was observed in R8's room at the bedside with the resident. The staff member was observed wearing a surgical mask, disposable gown and gloves. The staff member was observed to come outside of the room at 4:10 p.m. wearing the same gown and gloves and go to the medication cart across the hallway. The staff member was observed to open the medication cart with the gloves on and obtain medication for R8 and then return to the residents room. After administering the medication to R8, the staff member was observed to remove the gloves in the room and return to the medication cart with the same gown on at 4:12 p.m. The staff member was observed to doff the gown in trash can on the medication cart in the hallway at the medication cart at that time and sanitize their hands with alcohol based sanitizer.
The comprehensive care plan for R8 documented in part, The resident has infection/C-diff. Date Initiated: 06/27/2024. Revision on: 06/27/2024. Under Interventions it documented in part, .Maintain Contact precautions when providing resident care. Date Initiated: 06/27/2024. Revision on: 06/27/2024 .
The physician order's for R8 documented in part, Contact Isolation Precautions d/t positive C-diff every shift for positive for C-diff. Order Date: 07/29/2024.
On 7/30/24 at 1:12 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that when a resident was on contact precautions the staff were supposed to put on a gown and gloves before they went into the room. She stated that this was done to prevent the spread of germs. She stated that staff should wash their hands before they go in the room and when leaving the room and they normally used the alcohol based hand sanitizer unless their hands were soiled and then they washed their hands with soap and water.
On 7/30/24 at 4:12 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that R8 was on contact precautions for a diagnosis of C-diff. She stated that when staff go in the room they were to put on gloves and a gown prior to entering the room. She stated that they were supposed to take the gloves and gown off inside the room at the door prior to exit and normally there was a trash bin for them but R8's room did not have one. She stated that staff could use alcohol based hand sanitizer or wash their hands with soap and water after being in the room and only needed to use soap and water if they touched the resident directly.
On 7/31/24 at 12:57 p.m., an interview was conducted with CNA #1. CNA #1 stated that when a resident was on contact precautions there was a sign on the door telling them what they needed to wear in the room. She stated that contact precautions required gown and gloves and it was to protect themselves and prevent spread of infection. She stated that the gown and gloves should be worn anytime they went into the room and when a resident was diagnosed with C-diff they had to wash their hands with soap and water prior to leaving the room.
On 7/31/24 at 1:52 p.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was to alert all staff involved in the residents care what the goals were for that person and what the recommendations were for the safety of that resident. She stated that the care plan was used to track any improvement or decline in condition and it was to be implemented because it was part of the process to care for the resident.
On 7/31/24 at 2:57 p.m., an interview was conducted with ASM (administrative staff member) #2, the assistant director of nursing and infection preventionist. ASM #2 stated that R8 was on contact precautions for a diagnosis of C-diff and the expectation was for all staff to follow the signage on the door and put on a gown and gloves prior to entry. ASM #2 stated that the hand hygiene for C-diff diagnosed residents should be soap and water because it was more effective than alcohol based hand sanitizers. ASM #2 stated that there were no exceptions to following the isolation precautions.
The facility policy Care Planning- Comprehensive Person-Centered, undated, documented in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process .The resident will receive the services and/or items included in the plan of care .
On 7/31/24 at approximately 3:50 p.m., ASM #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services were notified of the findings.
No further information was provided prior to exit.
Reference:
(1) C. diff bacteria are commonly found in the environment, but people usually only get C. diff infections when they are taking antibiotics. That's because antibiotics not only wipe out bad germs, but they also kill the good germs that protect your body against infections. The effect of antibiotics can last as long as several months. If you come in contact with C. diff germs during this time, you can get sick. You are more likely to get a C. diff infection if you take antibiotics for more than a week. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=c.+diff+infections
2. For Resident #3 (R3), the facility staff failed to implement the comprehensive care plan to monitor the dialysis AV (arterio-venous) fistula (1) for function on 4/12-4/13/24, 5/30/24, 6/1-6-4/24 and 6/6/24.
The comprehensive care plan for R3 documented in part, The resident has ESRD (end stage renal disease) (2) and receives {Hemo/Peritoneal} dialysis . Date Initiated: 06/06/2024. Revision on: 06/07/2024 . Under Interventions it documented in part, .Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols. Date Initiated: 06/06/2024. Revision on: 06/07/2024 .
The physician orders for R3 documented in part, Assess Dialysis Fistula/Graft (left) for Thrill and Bruit Daily and signs and symptoms of infection. every shift. Order Date: 04/15/2024.
Review of the eTARs (electronic treatment administration records) for R8 dated 4/1/24-4/30/24, 5/1/24-5/31/24 and 6/1/24-6/30/24 failed to evidence assessment of the dialysis fistula on 4/12-4/13/24, 5/30/24, 6/1-6-4/24 and 6/6/24.
On 7/31/24 at 1:52 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to alert all staff involved in the residents care what the goals were for that person and what the recommendations were for the safety of that resident. She stated that the care plan was used to track any improvement or decline in condition and it was to be implemented because it was part of the process to care for the resident. LPN #1 stated that they worked with R3 at the facility. She stated that the staff should monitor a resident with a dialysis fistula each shift and they should check the site for bruit and thrill, look for any bleeding or signs of infection. She stated that this was evidenced by documentation in the clinical record.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing and infection preventionist and ASM #3, the regional director of clinical services were made aware of the findings.
No further information was provided prior to exit.
Reference:
(1) AV (arterio-venous) fistula: A vascular access is an opening made in your skin and blood vessel during a short operation. When you have dialysis, your blood flows out of the access into the hemodialysis machine. After your blood is filtered in the machine, it flows back through the access into your body. There are 3 main types of vascular accesses for hemodialysis. These are described as follows. Fistula: An artery in your forearm or upper arm is sewn to a vein nearby. This allows needles to be inserted into the vein for dialysis treatment. A fistula takes from 4 to 6 weeks to heal and mature before it is ready to use. Graft: An artery and a vein in your arm are joined by a U-shaped plastic tube under the skin. Needles are inserted into the graft when you have a dialysis. A graft can be ready to use in 2 to 4 weeks. Central venous catheter: A soft plastic tube (catheter) is tunneled under your skin and placed in a vein in your neck, chest, or groin. From there, the tubing goes into a central vein that leads to your heart. A central venous catheter is ready to use right away. It is usually used only for a few weeks or months . This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000591.htm
(2) end-stage kidney disease
The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.
3. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan to provide colostomy (1) care every shift during shifts on 3/8-3/11/24, 3/17/24, 3/26/24, 3/28/24, 3/29/24, 3/31/24, 4/12/24 and 5/3/24.
The comprehensive care plan for R4 documented in part, [Name of R4] has an alteration in gastro-intestinal status r/t (related to) Colostomy. Date Initiated: 10/26/2023. Revision on: 06/01/2024. Under Interventions it documented in part, Provide colostomy care Q (every) shift and PRN (as needed). Date Initiated: 10/26/2023. Revision on: 06/01/2024.
The physician orders for R4 documented in part, Colostomy Care as needed AND every shift On hold from 02/01/2024 23:13 to 02/03/2024 23:12. Order Date: 01/03/2024.
Review of the eTARs (electronic treatment administration records) for R4 dated 3/1-3/31/24, 4/1- 4/30/24 and 5/1-5/31/24 failed to evidence colostomy care provided during shifts on 3/8-3/11/24, 3/17/24, 3/26/24, 3/28/24, 3/29/24, 3/31/24, 4/12/24 and 5/3/24.
On 7/31/24 at 12:57 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that they worked with R4 at the facility. She stated that the CNA staff emptied the colostomy bags and burped the bag to let gas out. She stated that the nurses changed the bags and evidenced the care by charting it in the medical record.
On 7/31/24 at 1:52 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to alert all staff involved in the residents care what the goals were for that person and what the recommendations were for the safety of that resident. She stated that the care plan was used to track any improvement or decline in condition and it was to be implemented because it was part of the process to care for the resident. LPN #1 stated that colostomy sites were assessed daily and care was provided every shift when they worked.
On 7/31/24 at 3:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing and infection preventionist and ASM #3, the regional director of clinical services were made aware of the findings.
No further information was provided prior to exit.
Reference:
(1) Colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. This information was obtained from the website: https://medlineplus.gov/ency/article/002942.htm
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to maintain transmission based precautions as ordered for ...
Read full inspector narrative →
Based on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to maintain transmission based precautions as ordered for three of 15 residents in the survey sample, Residents #5, #8, and #10.
The findings include:
1. For Resident #5 (R5), the facility staff failed to maintain contact precautions for a diagnosis of C-diff (clostridium difficile) (1).
On 7/30/24 at approximately 10:22 a.m., an observation was made of the facility. Observation of R5's room revealed a sign posted outside of the door with stop signs on the corners of the notice. The signage documented Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A bin containing disposable gowns, gloves and trash bags was observed in the hallway near R5's room.
On 7/30/24 at 12:58 p.m., a facility staff member was observed entering R5's room carrying a lunch tray. The staff member was observed wearing a surgical mask with no other PPE (personal protective equipment). The staff member was observed touching contents of R5's overbed table to place the lunch tray on the table. The staff member was observed exiting R5's room and did not wash their hands. The staff member was observed obtaining another residents tray from the meal cart and entering another residents room to deliver the tray and was observed using alcohol-based sanitizer prior to exiting that room.
The comprehensive care plan for R5 documented in part, The resident has C. Difficile r/t (related to) recent antibiotic usage. Date Initiated: 07/12/2024.
The physician order's for R5 documented in part, Contact Isolation Precautions every shift for positive for C-diff. Order Date: 07/30/2024.
On 7/30/24 at 1:12 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that when a resident was on contact precautions the staff were supposed to put on a gown and gloves before they went into the room. She stated that this was done to prevent the spread of germs. She stated that staff should wash their hands before they go in the room and when leaving the room and they normally used the alcohol based hand sanitizer unless their hands were soiled and then they washed their hands with soap and water.
On 7/31/24 at 12:57 p.m., an interview was conducted with CNA #1. CNA #1 stated that when a resident was on contact precautions there was a sign on the door telling them what they needed to wear in the room. She stated that contact precautions required gown and gloves and it was to protect themselves and prevent spread of infection. She stated that the gown and gloves should be worn anytime they went into the room and when a resident was diagnosed with C-diff they had to wash their hands with soap and water prior to leaving the room.
On 7/31/24 at 2:57 p.m., an interview was conducted with ASM (administrative staff member) #2, the assistant director of nursing and infection preventionist. ASM #2 stated that the expectation when a resident was on contact precautions for a diagnosis of C-diff was for all staff to follow the signage on the door and put on a gown and gloves prior to entry. ASM #2 stated that the hand hygiene for C-diff diagnosed residents should be soap and water because it was more effective than alcohol based hand sanitizers. ASM #2 stated that there were no exceptions to following the isolation precautions.
The facility policy Hand hygiene, undated, documented in part, The facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene. All staff are to perform hand hygiene during all care activities and while working in all locations within the facility . Use soap and water: i. When hands are visibly soiled. ii. After caring for a person with know or suspected diarrhea. iii. After know of suspected exposure to spores such as C. difficile .
The facility policy Transmission-Based Precautions, undated, documented in part, . Contact precautions: .Personal Protective Equipment (PPE). A. Gloves. a. Staff and visitors will wear gloves when entering the room for all interactions that may involve contact with the resident and/or resident's environment. b. Staff and visitors will remove gloves and perform hand hygiene prior to leaving the resident's room . B. Gowns. a. Staff and visitors will wear a gown when entering the room for all interactions that may involve contact with the resident and/or the resident's environment. b. Staff and visitors will remove the gown and perform hand hygiene prior to leaving the resident's room .
According to the CDC (centers for disease control) C. diff fact sheet for healthcare professionals dated 3/15/24, documented in part, .C. diff spreads when people touch surfaces that are contaminated with poop from an infected person. Or when people don ' t wash their hands with soap and water . Healthcare professionals can help prevent C. diff by: . Wearing gloves and gowns when treating patients with
C. diff-and remembering that hand sanitizer doesn ' t kill C. diff . This information was obtained from the website: https://www.cdc.gov/c-diff/hcp/resources/
On 7/31/24 at approximately 3:50 p.m., ASM #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services were notified of the findings.
No further information was provided prior to exit.
Reference:
(1) C. diff bacteria are commonly found in the environment, but people usually only get C. diff infections when they are taking antibiotics. That's because antibiotics not only wipe out bad germs, but they also kill the good germs that protect your body against infections. The effect of antibiotics can last as long as several months. If you come in contact with C. diff germs during this time, you can get sick. You are more likely to get a C. diff infection if you take antibiotics for more than a week. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=c.+diff+infections
2. For Resident #8 (R8), the facility staff failed to maintain contact precautions for a diagnosis of C-diff (clostridium difficile) (1).
On 7/30/24 at 10:22 a.m., an observation was made of the facility. Observation of R8's room revealed a sign posted outside of the door with stop signs on the corners of the notice. The signage documented Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A bin containing disposable gowns, gloves and trash bags was observed in the hallway near R8's room.
On 7/30/24 at 12:45 p.m., a facility staff member was observed entering R8's room carrying a lunch tray. The staff member was observed wearing a surgical mask with no other PPE (personal protective equipment). The staff member was observed touching contents of R8's overbed table to make room for the lunch tray. The staff member was observed using alcohol based hand sanitizer prior to exit of R8's room.
On 7/30/24 at 4:09 p.m., a facility staff member was observed in R8's room at the bedside with the resident. The staff member was observed wearing a surgical mask, disposable gown and gloves. The staff member was observed to come outside of the room at 4:10 p.m. wearing the same gown and gloves and go to the medication cart across the hallway. The staff member was observed to open the medication cart with the gloves on and obtain medication for R8 and then return to the residents room. After administering the medication to R8, the staff member was observed to remove the gloves in the room and return to the medication cart with the same gown on at 4:12 p.m. The staff member was observed to doff the gown in trash can on the medication cart in the hallway at the medication cart at that time and sanitize their hands with alcohol based sanitizer.
The physician order's for R8 documented in part, Contact Isolation Precautions d/t positive C-diff every shift for positive for C-diff. Order Date: 07/29/2024.
The comprehensive care plan for R8 documented in part, The resident has infection/C-diff. Date Initiated: 06/27/2024. Revision on: 06/27/2024. Under Interventions it documented in part, .Maintain Contact precautions when providing resident care. Date Initiated: 06/27/2024. Revision on: 06/27/2024 .
On 7/30/24 at 1:12 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that when a resident was on contact precautions the staff were supposed to put on a gown and gloves before they went into the room. She stated that this was done to prevent the spread of germs. She stated that staff should wash their hands before they go in the room and when leaving the room and they normally used the alcohol based hand sanitizer unless their hands were soiled and then they washed their hands with soap and water.
On 7/30/24 at 4:12 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that R8 was on contact precautions for a diagnosis of C-diff. She stated that when staff go in the room they were to put on gloves and a gown prior to entering the room. She stated that they were supposed to take the gloves and gown off inside the room at the door prior to exit and normally there was a trash bin for them but R8's room did not have one. She stated that staff could use alcohol based hand sanitizer or wash their hands with soap and water after being in the room and only needed to use soap and water if they touched the resident directly.
On 7/31/24 at 12:57 p.m., an interview was conducted with CNA #1. CNA #1 stated that when a resident was on contact precautions there was a sign on the door telling them what they needed to wear in the room. She stated that contact precautions required gown and gloves and it was to protect themselves and prevent spread of infection. She stated that the gown and gloves should be worn anytime they went into the room and when a resident was diagnosed with C-diff they had to wash their hands with soap and water prior to leaving the room.
On 7/31/24 at 2:57 p.m., an interview was conducted with ASM (administrative staff member) #2, the assistant director of nursing and infection preventionist. ASM #2 stated that R8 was on contact precautions for a diagnosis of C-diff and the expectation was for all staff to follow the signage on the door and put on a gown and gloves prior to entry. ASM #2 stated that the hand hygiene for C-diff diagnosed residents should be soap and water because it was more effective than alcohol based hand sanitizers. ASM #2 stated that there were no exceptions to following the isolation precautions.
On 7/31/24 at approximately 3:50 p.m., ASM #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services were notified of the findings.
No further information was provided prior to exit.
Reference:
(1) C. diff bacteria are commonly found in the environment, but people usually only get C. diff infections when they are taking antibiotics. That's because antibiotics not only wipe out bad germs, but they also kill the good germs that protect your body against infections. The effect of antibiotics can last as long as several months. If you come in contact with C. diff germs during this time, you can get sick. You are more likely to get a C. diff infection if you take antibiotics for more than a week. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=c.+diff+infections
3. For Resident #10 (R10), the facility staff failed to maintain droplet precautions for a diagnosis of COVID-19 (1).
On 7/30/24 at approximately 10:22 a.m., an observation was made of the facility. Observation of R10's room revealed a sign posted outside of the door with stop signs on the corners of the notice. The signage documented Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. The signage documented photos of a person wearing a full face shield with mask or eye goggles and a mask. A bin containing disposable gowns, N95 masks (2), gloves and trash bags was observed near R10's room. No eye protection was observed in the bin near R10's room.
On 7/30/24 at 12:56 p.m., a staff member wearing a surgical mask was observed entering R10's room with a meal tray. The staff member was observed to not don a gown or gloves prior to entering the room and was observed delivering the tray to R10 on the window side of the room. The staff member was observed to sanitize their hands prior to exit from the room and return to the meal cart.
The comprehensive care plan for R10 documented in part, COVID-19: Confirmed Positive Resident has tested positive for COVID-19 and is symptomatic. Date Initiated: 07/24/2024.
The physician order's for R10 documented in part, Droplet Precautions. Order Date: 07/24/2024.
On 7/30/24 at 1:12 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that R10 was on droplet precautions for COVID-19 and that the staff were supposed to put on a mask, gown and gloves before they went into the room. She stated that this was done to prevent the spread of COVID-19. She stated that she was not sure about eye protection or a face mask.
On 7/31/24 at 12:57 p.m., an interview was conducted with CNA #1. CNA #1 stated that when a resident was on droplet precautions there was a sign on the door telling them what they needed to wear in the room. She stated that droplet precautions required a mask, gown and gloves and it was to protect themselves and prevent spread of infection.
On 7/31/24 at 2:57 p.m., an interview was conducted with ASM (administrative staff member) #2, the assistant director of nursing and infection preventionist. ASM #2 stated that the expectation when a resident was on droplet precautions for COVID-19 isolation was for staff to follow the signage on the door wearing the PPE (personal protective equipment) that it advised. He stated that the preferred mask was an N95 mask and that they stocked everything for the staff in the bins in the hallways. ASM #2 stated that there were no exceptions to following the isolation precautions.
The facility policy Coronavirus Disease (COVID-19)- Identification and Management of Ill Residents, created 3/23, documented in part, .Staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection will adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .
According to CDC (centers for disease control) guidance, dated 6/24/24 Infection Control Guidance: SARS-CoV-2, it documented in part, This guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health. The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency Personal Protective Equipment. HCP (health care providers) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . This information was obtained from the website: https://www.cdc.gov/covid/hcp/infection-control/
On 7/31/24 at approximately 3:50 p.m., ASM #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional director of clinical services were notified of the findings.
No further information was provided prior to exit.
Reference:
(1) COVID-19: COVID-19 most often causes respiratory symptoms that can feel much like a cold, the flu, or pneumonia. COVID-19 may attack more than your lungs and respiratory system. Other parts of your body may also be affected by the disease. Most people with COVID-19 have mild symptoms, but some people become severely ill. This information was obtained from the website: https://www.cdc.gov/covid/about/index.html
(2) The N95 respirator is the most common of the seven types of particulate filtering facepiece respirators. This product filters at least 95% of airborne particles but is not resistant to oil-based particles. This information was obtained from the website: https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence neurological assessment and monitoring after an unwitnessed ...
Read full inspector narrative →
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence neurological assessment and monitoring after an unwitnessed fall with head injury for one of six residents in the survey sample, Resident #1.
The findings include:
For Resident #1 (R1), the facility staff failed to evidence neurological check (1) monitoring after an unwitnessed fall with documentation of an injury to the forehead on 9/2/2023.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/28/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented no falls during the assessment period.
On 10/10/2023 at 11:57 a.m., an observation was made of R1 in their room. An interview was attempted with R1 but was not able to be conducted due to their cognition level. R1 was observed in bed with the bed in the lowest position and the call bell within reach. When asked about the fall on 9/2/2023, R1 did not respond appropriately to the question.
The progress notes for R1 documented in part,
- 09/02/2023 11:15 (11:15 a.m.) Note Text : Resident had unwitnessed fall in bathroom with injury. He refused to go to the ER (emergency room) and insisted he was fine. He joked about having a hard head and stated, .my friends are going to love this. Look what I can do when I get mean! He allowed me to take his vitals at the time of the incident but then again only once about 2 hours later. Vitals are as follows: (1)152/91 (blood pressure), 86 (pulse), 20 (respirations), 98% (oxygen), 97.6 (temperature) (2)147/83 (blood pressure), 80 (pulse), 18 (respirations), 97% (oxygen), 97.7 (temperature). Hospice was contacted and they said to continue to monitor him. If there was any change of condition, contact them. He has no c/o (complaints of) pain at this time. Denies dizziness or nausea.
- 09/02/2023 21:52 (9:52 p.m.) Note Text : Resident f/u (follow up) fall. No bruising or swelling to forehead noted. Denies pain or discomfort from fall. 136/80 (blood pressure), 84 (pulse), 18 (respirations), 98.3 (temperature), 02 sat (oxygen saturation) 98% RA (room air).
- 09/03/2023 06:54 (6:54 a.m.) Note Text : Post fall, no voiced complaints and no c/o pain. Resting quietly in bed. 98.2 (temperature)-89 (pulse)-18 (respirations) 156/78 (blood pressure), o2 sats 98%.
- 09/04/2023 06:31 (6:31 a.m.) Note Text : Post fall, no c/o pain, resting quietly in bed with eyes closed. 97.9 (temperature)-76 (pulse)-18 (respirations) 138/74 (blood pressure), o2 sats 98%.
- 09/06/2023 15:31 (3:31 p.m.) . Small abrasion to left forehead. No change in LOC (level of conscious), mental status or cognition. Refused to go to hospital .
The comprehensive care plan for R1 documented in part, (Name of R1) is at risk for falls, had an actual fall r/t (related to) muscle weakness. Date Initiated: 08/01/2023. Revision on: 09/07/2023.
On 10/10/2023 at 12:42 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing, for evidence of neurological monitoring for the unwitnessed fall on 9/2/2023.
On 10/10/2023 at 1:40 p.m., ASM #2 stated that they were unable to find any evidence of neurological checks for the requested fall for R1. She also stated that the LPN (licensed practical nurse) who documented the progress note regarding the fall on 9/2/2023 no longer worked at the facility and that CNA (certified nursing assistant) #1 worked with R1 on 9/2/2023 the day of the fall.
On 10/10/2023 at 2:30 p.m., an interview was conducted with LPN #1. LPN #1 stated that when a resident had an unwitnessed fall the nurse went in and assessed the resident. She stated that they attempted to find out what happened and notified the physician and the family. She stated that they completed a risk management report which guided the nurse to complete a fall risk assessment, a progress note, neuro checks and other required documentation. She stated that they reviewed the care plan and updated it with any new interventions as necessary. She stated that an unwitnessed fall or a fall with head injury required the nurses to perform neuro checks per the facility protocol for 72 hours. She stated that the nurses used a paper form which had the instructions on how they were to be obtained during the 72 hours. She stated that she was aware that R1 had fallen in the bathroom and had refused to go out to the hospital to get checked and she would have expected for neuro checks to have been done after the fall.
On 10/10/2023 at 1:44 p.m., an interview was conducted with CNA #1. CNA #1 stated that R1 had told her that they had fallen in their bathroom but they did not think that they were working that day. She stated that R1 required supervision with toileting prior to their most recent hospitalization.
On 10/10/2023 at 4:37 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they were not working the day of R1's fall. She stated that when a resident had an unwitnessed fall or if they hit their head the nurses followed a neuro check protocol. She stated that residents were monitored for 72 hours following the neuro check flowsheet and they assessed the residents pupils, hand grasps, orientation, range of motion, speech and vital signs.
The facility policy Fall Protocol undated, documented in part, . Actual Fall . 3. The resident will be monitored for change in condition q (every) shift for 72 hours; unless otherwise ordered by the physician/practitioner. a. Monitoring may include physical assessment of the resident, vital signs, neurological checks [if resident hit head or fall was unwitnessed], assessment for pain, swelling, redness, or impaired skin .
The facility Neurological Evaluation Flow Sheet dated 6/20, documented in part, Directions: Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours) .Level of Consciousness .Orientation .Pupils .Motor Movement Evaluation .Communication/Language .Unusual/New Observations .Vital Signs .
On 10/10/2023 at 4:49 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse consultant were made aware of the findings.
No further information was provided prior to exit.
Reference:
(1) Neuro checks
neuro-checks-a series of quick questions and tasks that help healthcare providers assess how well a TBI patient's brain and body are working-some in-depth tests help reveal levels of injury or damage in TBI patients. This information was obtained from the website: https://www.nichd.nih.gov/health/topics/tbi/conditioninfo/diagnose
Sept 2023
30 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
Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow the plan of care for transpo...
Read full inspector narrative →
Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow the plan of care for transporting a resident which resulted in an injury for one of 40 residents in the survey sample, Resident #33. The resident sustained a fracture of the right femur (1) which constituted harm, cited at past non-compliance.
The findings include:
For Resident #33 (R33), the facility staff failed to provide support to the resident's feet while transporting them in the wheelchair in the facility hallway, which resulted in the resident's feet dropping to the floor which caused R33 to fall from the wheelchair and subsequently sustained a fractured femur.
On R33's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/10/2023, the resident was not assessed for cognition. Section G documented R33 using a wheelchair and having range of motion impairment on one side in the upper and lower extremity. Section GG documented R33 being non-ambulatory and using a manual wheelchair. Section J documented R33 having a fall with fracture related to a fall in the past 6 months.
On the residents MDS prior to the injury, a quarterly assessment with an ARD of 5/25/2023, the resident was assessed as being modified independent in making daily decisions. Section G documented R33 using a wheelchair and having range of motion impairment on one side in the upper extremity and both side in the lower extremities. Section GG documented R33 being non-ambulatory and using a manual wheelchair. It further documented R33 being dependent to wheel 50 feet with two turns and wheel 150 feet in a corridor or similar space. Section J documented R33 not having any falls.
On 9/21/2023 at 8:34 a.m., an interview was conducted with R33. R33 stated that they had not really been told what happened that day but remembered that their feet were hanging off the wheelchair and they just went forward from the chair onto the floor.
The progress notes for R33 documented in part,
- 7/28/2023 12:29 (12:29 p.m.) Note Text: CNA (certified nursing assistant) propelling resident to the shower room in her w/c (wheelchair) at 1030am when residents feet with sneakers on fell to the floor and caused resident to fall out of the w/c in the hallway. Assisted from floor by 3 staff members. Denies pain. States she feels fine. ROM (range of motion) performed without any new limitation or pain. RP (responsible party) and DR (doctor) notified. Will cont (continue) to monitor.
- 7/28/2023 15:22 (3:22 p.m.) Note Text: Resident c/o (complains of) pain 6/10 (six out of possible ten) to right groin and thigh. Voltaren gel applied to area. NP (nurse practitioner) called and notiifed [sic] with N.O. (new order) Right hip and right femur X-RAY STAT (now) s/p (status post) fall. RP (responsible party) aware. X-ray called in and awaiting arrival.
- 7/28/2023 22:47 (10:47 p.m.) Note Text: X-ray to right hip and femur completed this shift, awaiting for result. Resident complained of level 2/10 pain when moving in the bed was medicated with 2 Tylenol with good relief.
- 7/29/2023 07:00 (7:00 a.m.) Note Text: Received X ray result finding sub capital fracture acute of the right femoral neck without dislocation left (name of physician) message via on call, waiting for call back. report given to oncoming nurse.
- 7/29/2023 07:52 (7:52 a.m.) Note Text: N.O. received to send resident to ED (emergency department) r/t (related to) r (right) femur fx (fracture).
- 8/2/2023 15:30 (3:30 p.m.) Note Text: Readmit to facility from Acute Care Hospital for repair and treatment of right hip fracture. Surgical procedure was performed to right hip, dressing dry and intact, no bleeding. Vital signs: 98.7 (temperature),98 (pulse),18 (respirations),118/61 (blood pressure), 94% (oxygen saturation). Skin warm and dry, moving right leg slowly. positive pedal pulses.
The comprehensive care plan for R33 documented in part, ADL (activities of daily living) Self care deficit as evidenced by related to weakness, femur fracture. Date Initiated: 05/18/2019. Revision on: 08/02/2023. The care plan further documented, At risk for falls, had an actual fall due to weakness. Date Initiated: 05/18/2019. Revision on: 08/02/2023.
Review of the fall investigation completed for R33 dated 7/28/2023 documented in part, .Incident Description: Nursing Description: CNA propelling resident to the shower room in her w/c at 1030am when residents feet with sneakers on fell to the floor and caused resident to fall out of the w/c in the hallway. Assisted from floor by 3 staff members. Denies pain. States she feels fine. ROM performed without any new limitation or pain. RP and DR notified. Will cont to monitor . Immediate Action Taken: Description: Resident did not hit her head. Head to toe assessment done. No visible injury noted. V/S (vital signs) and ROM WNL (within normal limits). Assisted back to w/c. Complaining of right hip, leg pain. NP notified. Order received and carried out to order STAT x-ray of right hip and right femur. RP notified. Pain medication administered. Leg rests provided on wheelchair. Resident taken to Hospital? N (no) .No injuries observed post incident.
On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, stated that the CNA who was pushing R33 in the wheelchair on 7/28/2023 when the injury occurred no longer worked at the facility and could not be interviewed. ASM #4, the regional nurse consultant stated that the facility had an action plan that had been put in place after R33's injury and would provide it for review.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they were unsure if they were working the day of R33's injury or not. She stated that the team had discussed the fall and injury in their morning meeting after they had been sent out to the hospital. She stated that R33 was wheelchair bound prior to the injury and required staff to push them around the halls. She stated that any residents that were unable to propel themselves in the wheelchair should have leg rests on the chairs to support the feet.
On 9/21/2023 at 10:18 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that they were in the building on 7/28/2023. She stated that the staff notified them that they were calling the nurse practitioner and had gotten the order for the stat x-ray. She stated that the staff reported to her that they were taking the resident for their scheduled shower, and they had put their feet down with their shoes on and went forward. She stated that R33 was a one person assist, wheelchair bound and required staff to propel them in the wheelchair prior to the incident. She stated that from their staff interviews and investigation they had determined that the CNA did not have the leg rests on the wheelchair and had the resident holding their feet up. She stated that this led them to put an action plan in place. She stated that the expectation for staff was to make sure that the leg rests were in place prior to transporting the resident.
On 9/21/2023 at 10:35 a.m., an interview was conducted with CNA #9. CNA #9 stated that anytime they needed to transport a resident who required them to push their wheelchair they made sure they had leg rests on the chair. She stated that if the resident did not have leg rests, they went to the therapy department to obtain some. She stated that they did this so the resident's feet did not drag because it could cause skin breakdown and was also a safety issue.
On 9/21/2023 at 10:41 a.m., an interview was conducted with CNA #10. CNA #10 stated that residents had leg rests on the wheelchair for use during transport by staff unless therapy determined that the resident needed to strengthen their lower extremities by self-propelling. She stated that R33 was able to use their arms to propel themselves in the wheelchair short distances at times.
On 9/21/2023 at 11:47 a.m., an interview was conducted with RN (registered nurse) #6. RN #6 stated that they were in the hallway administering medications on 7/28/2023 when the CNA was pushing R33 in the wheelchair. She stated that the CNA came past them with R33 in the wheelchair and then she saw R33 roll out of the chair a few steps in front of her. She stated that R33 did not hit their head, did not complain of any pain, or have any abnormalities in vital signs or the head-to-toe assessment so they had just monitored them at that time. She stated that R33 was in the wheelchair without leg rests with their feet hanging down and had sneaker on with grips on them and they thought when their foot dropped down on the carpet it had gripped the carpet and propelled them forward out of the chair. She stated that she had advised the CNA to go to the room to get the leg rests for the chair, but they could not be located. She stated that R33 was fine until later in the shift when they started to complain of pain, so they had contacted the nurse practitioner and ordered the x-ray. She stated that R33 normally was always propelled in the wheelchair by staff prior to the incident and they had only seen them propel only a few steps in the hallway.
On 9/21/2023 at approximately 8:00 a.m., ASM #1, the administrator provided an action plan for R33 with a completion date of 8/4/2023. Review of the action plan documented corrective action plan for R33, identification of other residents potentially affected, measures the facility will take, quality assurance plans to monitor facility performance and a completion date for the action plan.
On 9/21/2023 at approximately 8:20 a.m., a request was made to ASM #1, the administrator for evidence of completion of the action plan.
On 9/21/2023 at 8:40 a.m., ASM #1 provided a folder with evidence of completion of the action plan. Review of the action plan documented: 1) one on one education to the CNA involved regarding application of leg rest/footrest on any residents that are dependent with locomotion. 2) An audit completed of all residents in the facility identifying other residents potentially affected. 3) Audits completed on 8/11/2023, 8/18/2023, 8/25/2023, 9/1/2023, 9/8/2023 and 9/15/2023 of dependent wheelchair residents to determine if leg rests were available and 25% care plan audits. It further documented education provided to licensed staff members (CNA, LPN, RN) on wheelchair dependent residents- ensure leg rests are available for chair & place order for leg rests if not available conducted by the director of nursing on 8/3/2023. 4) An ad hoc QAPI (quality assurance performance improvement) meeting agenda/summary dated 8/3/2023 documenting the administrator, MDS coordinator, unit manager and director of nursing meeting regarding Management of transporting dependent wheelchair residents in wheelchairs and where wheelchair dependence is documented.
Review of the plan of correction provided by ASM #1 for R33's injury on 7/28/2023 documented a date of compliance of 8/4/2023. Verification of the facility plan of correction was completed by observations, staff interviews and review of the facility audits, staff education and resident audits. No concerns were identified.
Observations of current residents being transported by facility staff were conducted during the survey dates. There were no current concerns identified.
On 9/21/2023 at 12:08 p.m., ASM #1, the administrator and ASM #4, the regional nurse consultant were made aware of the concern for harm. No further information was provided prior to exit.
Based on the acceptable plan of correction, all components of the plan verified, and no concerns identified during the survey, this deficient practice is cited at past non-compliance.
Reference:
(1) femur fracture
You had a fracture (break) in the femur in your leg. It is also called the thigh bone. You may have needed surgery to repair the bone. You may have had surgery called an open reduction internal fixation. In this surgery, your surgeon will make a cut to open your fracture. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000166.htm.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ...
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, the facility staff failed to provide care and services to prevent and treat pressure injuries for three of 40 residents in the survey sample, Residents #106, #108 and #96. For Resident #106, the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries, failed to obtain physician's orders for the treatment of the pressure injuries, and failed to implement interventions to prevent further pressure injuries, which constituted harm.
The findings include:
1. For Resident #106 (R106), upon admission on [DATE], the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries on the sacrum, left hip, right heel and left heel, failed to obtain physician's orders for treatments for those pressure injuries, and failed to implement interventions to prevent further pressure injuries. On 6/8/23, the wound care physician identified more unstageable (1) pressure injuries on the right great toe and left great toe.
R106 was admitted to the facility on [DATE]. The admission screener assessment dated [DATE] documented R106 presented with no skin issues; however, during an interview with RN (registered nurse) #4, the nurse who documented the admission screener assessment, RN #4 stated R106 refused a skin assessment on 5/18/23 and she did not complete a skin assessment until 5/19/23. RN #4 stated that during the 5/19/23 skin assessment, she identified multiple pressure injuries, and they were later documented in a skin note dated 6/7/23. The pressure injuries documented in RN #4's skin note dated 6/7/23 were an unstageable pressure injury on the sacrum, an unstageable pressure injury on the right heel, an unstageable pressure injury on the left heel, and a stage two (1) pressure injury on the left hip.
The facility staff failed to assess the resident's risk for pressure injuries (until 5/23/23 when the resident was assessed as being at moderate risk for pressure injuries), failed to develop a care plan for pressure injuries (until 6/27/23), and failed to obtain physician's orders to implement interventions to prevent and treat pressure injuries (until 6/8/23). On 6/8/23, the wound care physician evaluated R106 and ordered treatments for six different pressure injuries. These pressure injuries included the four pressure injuries documented in RN #4's 6/7/23 skin note; an unstageable pressure injury on the sacrum, an unstageable pressure injury on the left hip, an unstageable pressure injury on the right heel and a deep tissue injury on the left heel, and two new pressure injuries which were an unstageable pressure injury on the right great toe and an unstageable pressure injury on the left great toe.
A hospital Discharge summary dated [DATE] failed to reveal any documentation regarding pressure injuries. R106 was admitted to the facility on [DATE]. No assessment for risk for pressure injuries was completed on the date of admission. R106's admission screener (assessment) dated 5/18/23 documented the resident had no skin issues. The baseline care plan triggers section of the screener revealed no focus, goals, or interventions related to R106's skin integrity.
R106's care plan initiated on 5/18/23 failed to document any information regarding skin integrity and pressure injuries, until 6/27/23.
A physical therapy evaluation dated 5/19/23 documented R106 was totally dependent with bed mobility and presented with unstageable bilateral heel pressure areas (injuries). Further review of R106's clinical record failed to reveal any further documentation regarding the bilateral heel pressure injuries until 5/22/23. A nurse's note dated 5/22/23 documented, It was reported by therapy that resident has large ulcers on heels. On arrival resident has unstageable ulcers (injuries) on both heels and stage 1 (1) ulcer on both side of the foot and ankle. Wiped down with skin prep. A review of physician's orders, the medication administration record and the treatment administration record for May 2023 failed to reveal any treatments for the pressure injuries.
A review of nurse practitioner and physician notes from 5/19/23 through 5/24/23 failed to reveal any documentation regarding pressure injuries. The notes dated 5/19/23, 5/22/23, 5/23/23 and 5/24/23 documented, SKIN: No rash, ulcer or cyanosis. Warm and dry. No induration, nodules, or discoloration .
A Braden scale for predicting pressure sore (injury) risk dated 5/23/23 had documented that R106 was at moderate risk for pressure injuries.
A review of physician's orders, the medication administration record, and the treatment administration record for May 2023 and June 2023 failed to reveal any treatments for any pressure injuries until 6/8/23.
Physician notes dated 6/2/23 and 6/7/23 documented, SKIN: (Name) indicated that patient has dark area on both heels. Wound care team to follow. Warm and dry. No induration, nodules, or discoloration .
A skin note dated 6/7/23 and signed by RN (registered nurse) #4 (the nurse who documented the admission screener) documented, Resident was noted to have an unstageable ulcer (pressure injury) measuring 7 cm (centimeters) x 10 cm in circumference in the sacrum. 5 cm x 7 cm stage II (1) ulcer on the lateral aspect of the left upper thigh, fluid filled in the center and surrounding tissues red and irritated. 4 cm x 4.5 cm unstageable ulcer on both heels. Scattered bruises on the left lower leg and foot. Sacral and left hip wound were cleansed with wound cleanser and dry dressing applied.
A progress note signed by the wound care physician on 6/8/23 documented, Physical Exam. Constitutional: The pulse has a regular rate and rhythm. The patient is afebrile. The patient appears well nourished and has a normal weight .Wound Assessments(s)
-Wound #1 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 8 cm length x 9 cm width with no measurable depth, with an area of 72 sq (square) cm. There is Moderate amount of serous drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar .
-Wound #2 Left Hip is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6 cm length x 3 cm width with no measurable depth, with an area of 18 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar .
-Wound #3 Right Heel is an Unstageable Pressure Injury Obscured full-thickness and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6 cm length x 6 cm width with no measurable depth, with an area of 36 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar .
-Wound #4 Left Heel is a Deep Tissue (1) Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5 cm length x 6 cm width with no measurable depth, with an area of 30 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% epithelialization .
-Wound #5 Right Great Toe is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1 cm length x 1 cm width with no measurable depth, with an area of 1 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar .
-Wound #6 Left Great Toe is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1 cm length x 1 cm width with no measurable depth, with an area of 1 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar .
Weekly Wound Evaluations with an effective date of 6/8/23 and signed by LPN (licensed practical nurse) #3 on 6/9/23, documented similar assessments for all pressure injuries documented by the wound physician, documented the measurements were obtained by the wound care provider, and documented the pressure injuries as new skin concerns and facility acquired.
Treatment orders for all of the pressure injuries were not obtained until 6/8/23 and included:
1. Bactrim DS (double strength) (an antibiotic) 800-160 mg (milligrams)- one tablet by mouth two times a day for wound infection for 14 days.
2. Medihoney (medical grade honey)- Apply to left hip topically every evening shift for skin alteration. Cleanse area with wound cleanser, apply honey, cover with foam dressing.
3. Medihoney- Apply to sacrum topically every evening shift for skin alteration. Cleanse area with wound cleanser, apply medihoney, cover with foam dressing.
4. Paint bilateral great toes with betadine (antiseptic used to treat skin infections) every evening shift for skin alteration.
5. Paint bilateral heels with betadine every evening shift for skin alteration.
On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who documented the 6/8/23 weekly wound evaluations). LPN #3 stated a Braden assessment, and a head-to-toe skin assessment should be completed for all residents upon admission. LPN #3 stated if a resident does present with a pressure injury on admission, then staff have to make sure the resident has an air loss mattress and nurses should check the hospital discharge instructions for wound care orders. LPN #3 stated that if the discharge instructions do not contain wound care orders, then nurses should call the doctor or nurse practitioner to obtain wound care orders. LPN #3 stated that within 24 hours of admission, residents must have a second skin assessment in case the first nurse missed something. LPN #3 stated nurses are supposed to develop a care plan on admission and the care plan should include a risk for skin alteration for all residents and include pressure injuries if the resident has pressure injuries. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident's skin. LPN #3 stated if a new area is observed, the nurse should assess the pressure injury, document the assessment, notify the doctor, notify the family, initiate a treatment order, and update the care plan. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record.
On 9/20/23 at 10:10 a.m., an interview was conducted with RN #4, the nurse who documented the admission screener assessment and the 6/7/23 nurse's note. RN #4 stated R106 refused a skin assessment on the day of admission but per the report she received from the transferring facility, the resident did not have skin issues, so she documented no skin issues on the admission assessment. RN #4 stated the next day, she inspected R106's skin and the resident had a tremendous number of wounds. RN #4 could not remember details about the wounds but stated she documented the wounds in the clinical record. RN #4 stated that after this, the staff got the doctor involved because the doctor has to give orders for how to clean the wounds. (Note: RN #4 did not document a progress note regarding R106's pressure injuries until 6/7/23 and physician's orders were not obtained until 6/8/23 after the wound care physician evaluated the pressure injuries).
On 9/20/23 at 10:26 a.m., an interview was conducted with LPN #9, the nurse who documented the 5/22/23 nurse's note. LPN #9 did not remember R106 or any information about R106.
On 9/20/23 at 3:19 p.m., an interview was conducted with ASM (administrative staff member) #3 (the wound care physician). ASM #3 stated he could not provide information about R106's pressure injuries before he observed the pressure injuries. ASM #3 stated R106 was highly non-compliant with care, and he could understand why staff could have a tough time determining what treatments to use for R106's pressure injuries because of the amount of pressure injuries. ASM #3 stated he tells the staff to call him anytime and not wait until his weekly visit.
On 9/20/23 at 3:37 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concerns and the concern for harm.
On 9/21/23 at 11:28 a.m., an interview was conducted with OSM (other staff member) #7 (R106's physical therapist). OSM #7 stated he is not responsible for conducting total body skin assessments, but he completes range of motion assessments and tests residents' strength and mobility so if a resident complains of something unusual or pain, he checks to see the cause of limited mobility or pain. OSM #7 stated on 5/19/23, R106 complained of pain in both feet so he removed the resident's socks and saw unstageable pressure injuries that were closed, looked blackish blue but not yet eschar. OSM #7 stated he reported the pressure injuries to the nursing staff on 5/19/23.
On 9/21/23 at 12:18 p.m., a call was placed to R106's nurse practitioner but she was not available for interview.
The facility policy titled, Pressure Injury Prevention And Management documented, The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries, (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: -Promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury. SPECIFIC PROCEDURES/GUIDANCE: Risk Assessments- 1. Pressure ulcer/injury risk assessments will be conducted on admission/re-admission to the nursing facility. a. Upon admission, a risk assessment will be completed weekly for the first four weeks .3. Pressure ulcer/injury risk assessments will be conducted by a licensed/registered nurse and will be documented in the resident's medical record using the facility defined format/tool. 4. Findings from the pressure ulcer/injury risk assessment will be incorporated into the resident's plan of care. Preventative Measures- 1. Preventative interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences .Identification- 1. Staff will be encouraged to promptly report any observation of a change in the resident's skin integrity. 2. Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record. 3. Observations of new pressure ulcer/injury will be: a. Reported to the physician/practitioner for further evaluation and treatment. b. Referred to the designated wound nurse as appropriate. Evaluation/Assessments- 1. Evaluation/assessment of pressure ulcer/injury will be completed weekly and with significant change in condition of the ulcer/injury by a licensed nurse and/or practitioner. 2. Documentation of the evaluations/assessment of the pressure ulcer/injury will [sic] maintained in the resident's medical record. Documentation may include: a. Location of ulcer/injury. b. Date that the ulcer/injury was acquired [when known]. c. Description of the ulcer/injury to include stage, measurements [length, width, depth], present/absence of any tunneling or undermining, type of tissue [epithelial, granulation, slough, necrosis, etc.], presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain with the ulcer/injury. d. Treatment and interventions to promote healing .Treatment Protocols- 1. Treatments will be ordered by the physician/practitioner .3. The effectiveness of the pressure ulcer/injury treatment will be evaluated weekly during the weekly evaluation/assessment of the wound. If improvement in the wound is not seen within two weeks, the physician/practitioner will be contacted with the assessment and alternative treatment measures obtained as indicated .5. Treatments, including preventative interventions, will be documented in the resident's medical record .Care Plans- 1. A resident centered care plan will be developed and implemented to address the resident's risk for development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury .
Reference:
(1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a
bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear .
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin.
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister .
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss.
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue) .
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration.
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister .
This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
2. For Resident #108 (R108), the facility staff failed to complete thorough assessments of the resident's stage four pressure injury (1) in August 2023 and September 2023, failed to assess R108 for self-care of the pressure injury, and failed to provide oversight to ensure treatments were being completed for the pressure injury in August 2023 and September 2023.
R108 was admitted to the facility on [DATE] with a diagnosis of a stage four pressure injury on the sacral region. R108's comprehensive care plan dated 6/4/23 documented, I have actual impairment to skin integrity r/t (related to) right ischium (inaccurate documentation of location). Assess/Monitor/Document wound: size, depth, margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis per facility protocols. Notify MD (medical doctor) as indicated .
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/8/23/23, 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 weekly wound evaluation dated 7/21/23 documented R108 presented with a stage four pressure injury on the right ischial (inaccurate documentation of location), present on admission, and measuring 4.5 cm (centimeters) in length by 4 cm in width by 2 cm in depth.
On 9/20/23 at 1:10 p.m., an interview was conducted with R108. R108 stated he has had a wound on his buttock for over three years. R108 stated the nurses only look at the wound when he asks, and the nurses have not measured the wound, In a while. R108 stated he completes treatment for the wound twice a day and the treatment consists of soaking gauze in saline, putting the gauze in the wound, applying an adhesive bandage then covering that with another adhesive bandage.
A review of R108's clinical record failed to reveal thorough assessments of the pressure injury in August 2023 and September 2023. The only documentation regarding the resident's skin was a weekly skin observation dated 8/7/23 that documented no open areas, a weekly skin observation dated 8/15/23 that documented an open area on the left buttock, a weekly skin observation dated 8/21/23 regarding another skin concern but did not contain any documentation regarding the pressure injury, a weekly skin observation dated 8/29/23 that documented no open areas, and a weekly skin observation dated 9/6/23 that documented an open area on the left buttock. The weekly skin observations failed to document a description of the pressure injury (including stage, measurements, presence or absence of any tunneling or undermining, type of tissue, or presence or absence and type of drainage).
Further review of R108's clinical record failed to reveal the resident was assessed for self-care of the pressure injury to ensure the resident was capable of caring for the pressure injury, and failed to reveal oversight was provided to ensure the resident was providing care for the pressure injury per the physician's order. A physician's order dated 6/28/23 documented to cleanse the wound to the right buttock with normal saline, apply normal saline soaked gauze to the open area, and cover with a dry adhesive dressing every shift for wound care. A review of R108's August 2023 and September 2023 TARs (treatment administration records) revealed the same physician's order but failed to reveal documentation that the treatments were completed each day for both months. The spaces for nurses to sign off the completion of the treatments were blank. Review of nurses' notes for August 2023 and September 2023 failed to reveal documentation that treatments for R108's pressure injury were completed. The only documentation of refusal of care in August 2023 and September 2023 was a nurse's note dated 8/3/23 that documented R108 declined to be seen by the wound care physician and a nurse's note dated 8/26/23 that documented R108 refused wound treatment with the wound physician.
On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident's skin. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record.
On 9/21/23 at 9:16 a.m., another interview was conducted with LPN #3. LPN #3 stated an evaluation should be completed to make sure a resident is safe and able to perform his own pressure injury care. LPN #3 stated nurses should make sure the resident has the supplies he needs for wound care, make sure the doctor is aware the resident performs his wound care, and nurses should offer assistance if needed. LPN #3 stated this should be done each time the wound care is due per the physician's order. LPN #3 stated she had not personally assessed R108's pressure injury on the buttock since June or July 2023 but she observed R108 perform wound care on the previous Monday. LPN #3 stated she observed the resident lay on his side and spread out and clean and pack the wound. LPN #3 stated she thought R108 was using a wet to dry dressing and a border gauze for his pressure injury treatment. LPN #3 stated she did not document this observation and needed to complete a late entry.
On 9/21/23 at 1:28 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) Stage 4 Pressure Injury: Full-thickness skin and tissue loss.
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
3. For Resident #96 (R96), the facility staff failed to complete thorough assessments of the resident's stage three pressure injury (1) in August 2023 and September 2023, and failed to provide treatments per physician's orders on multiple dates in September 2023.
R96 was admitted to the facility on [DATE] with a diagnosis of a stage three pressure injury of the sacral region (1). An admission evaluation dated 8/24/23 documented an open pressure area on the sacrum. A weekly skin observation note dated 8/25/23 documented R96 was admitted with an open area to the sacrum measuring 1.5 cm (centimeters) (length) by 1.5 cm (width). A weekly skin observation dated 9/4/23 documented, Resident was admitted with an open area to sacrum (1.5cm x 1.5cm). A weekly skin observation dated 9/11/23 documented, Open area and Cleanse sacral wound with wound cleanser. Apply calcium alginate (used to treat wounds) to wound bed cover with foam dressing. A weekly skin observation dated 9/19/23 documented, admitted with open area to sacrum. The weekly skin observations failed to document a description of the pressure injury (including stage, measurements [8/24/23, 9/11/23 and 9/19/23], presence or absence of any tunneling or undermining, type of tissue, or presence or absence and type of drainage).
Further review of R96's clinical record revealed the following physician's orders:
8/24/23- clean the sacral area with normal saline and cover with form board gauze daily (discontinued 9/8/23).
9/8/23- cleanse the sacral wound with wound cleanser. Apply calcium alginate to wound bed and cover with foam dressing every day shift.
A review of R96's September 2023 TARs (treatment administration records) revealed the same physician's orders but failed to reveal documentation that the treatments were completed on 9/1/23, 9/4/23, 9/8/23, 9/10/23, 9/11/23, 9/14/23 and 9/15/23. The spaces for nurses to sign off the treatments had been done were blank. A review of nurse's notes for all dates also failed to reveal documentation that the treatments were completed.
On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident's skin. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record.
On 9/21/23 at 1:28 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) Stage 3 Pressure Injury: Full-thickness skin loss.
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and
epibole (rolled wound edges) are often present. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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...
Read full inspector narrative →
**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 residents dignity for one of 40 residents in the survey sample, Resident #120.
The findings include:
The facility staff failed to ensure a resident's dignity for Resident #120 as his urinary catheter bag had no privacy covering during observations on 9/19/23 at 1:45 PM, 9/20/23 8:10 AM and 9/20/23 at 4:15 PM.
Resident #120 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, BPH (benign prostatic hypertrophy).
A review of the baseline care plan dated 9/14/23, which revealed, FOCUS: The resident has Indwelling Catheter:
history of BPH. INTERVENTIONS: The resident has 16 FR/10cc Position catheter bag and tubing below
the level of the bladder and away from entrance room door. Dignity bag to cover drainage bag content.
On 9/19/23 at 1:45 PM, 9/20/23 8:10 AM and 9/20/23 at 4:15 PM, Resident #120 was observed in their room and the uncovered urinary drainage bag, which contained urine in it, was visible from doorway.
On 9/20/23 at 8:10 AM an interview was conducted with RN (registered nurse) #2. When asked if a urinary catheter bag has no privacy covering, is the resident's dignity being maintained, RN #2 stated, no, it is not.
On 9/21/23 at 9:15 AM an interview was conducted with LPN (licensed practical nurse) #3. Asked if a resident's dignity is maintained if their urinary bag has no privacy covering, LPN #3 state, no, their dignity is not maintained.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
A review of the facility's Dignity policy revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to pr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that written RP (responsible party) and ombudsman notification was provided when three of 40 residents in the survey sample were transferred to the hospital, Residents #49, Resident #33, and Resident #11.
The findings include:
1. The facility staff failed to evidence provision of required written notification was provided to the RP (responsible party) and ombudsman at the time of discharge for Resident #49. Resident #49 was transferred to the hospital on 7/19/23.
Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes, congestive heart failure, COPD (chronic obstructive pulmonary disease) and acute respiratory failure. Resident #
A review of Resident #49's eINTERACT (interventions to reduce acute care transfer) form dated 7/19/23 revealed, COPD, shortness of breath. Sent to hospital.
An interview was conducted on 9/20/23 at 2:30 PM with LPN (licensed practical nurse) #2. When asked who provides written notification to the RP and ombudsman, LPN #2 stated, We call the family, but social services sends them something I believe. They also contact the ombudsman.
An interview was conducted on 9/21/23 at 9:48 AM with OSM (other staff member) #4, the director of social services. When asked who provides written RP and ombudsman notification, OSM #4 stated, The complete list of discharges every month is sent to the ombudsman and she takes the list and reviews it. I keep a binder of the original list. I mail it to the resident's house or give it to the resident if they are responsible. I have not found a blank copy of the notice of discharge form that I can use. Date of transfer, where and why they were sent out and date of form are mailed out to the RP.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
A review of the facility's Facility Initiated Transfer or Discharge policy revealed Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The written notice will include the following: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities and the facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The copy of the notice to the ombudsman will be sent at the same time notice is provided to the resident and resident representative. Copies of notices for emergency transfers will be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.
No further information was provided prior to
2. For Resident #33 (R33), the facility staff failed to provide evidence that written notification of transfer was provided to the resident and/or responsible party, or the long-term care ombudsman for a facility-initiated transfer on 7/29/2023.
A review of R33's clinical record revealed the following progress notes:
- 7/29/2023 07:52 (7:52 a.m.) N.O. (new order) received to send resident to ED (emergency department) r/t (related to) r (right) femur fx (fracture).
- 8/2/2023 15:30 (3:30 p.m.) Note Text: Readmit to facility from Acute Care Hospital for repair and treatment of right hip fracture. Surgical procedure was performed to right hip, dressing dry and intact, no bleeding .
Further review of the clinical record failed to reveal evidence that written notification of transfer was provided to the resident and/or responsible party or the long-term care ombudsman for the transfer on 7/29/2023.
On 9/20/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of written notification of transfer provided to the resident and/or responsible party and the long-term care ombudsman for the transfer on 7/29/2023 for R33.
On 9/21/2023 at approximately 8:00 a.m., ASM #1 stated that they did not have any evidence of written notification of transfer provided to the resident and/or responsible party and the long-term care ombudsman for the transfer on 7/29/2023 for R33.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the nursing staff did not provide any written notification of transfer to the resident or the responsible party when they went to the hospital. She stated that they notified the family by telephone of the transfer and was not sure who was responsible for ombudsman notification.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN #3. LPN #3 stated that the nursing staff made a phone call to the family when the resident was transferred to the hospital but did not send a written notification of transfer. She stated that she thought that the social worker sent the written notification of transfer and the ombudsman notification of transfer.
On 9/21/2023 at 9:48 a.m., an interview was conducted with OSM (other staff member) #4, the director of social services. OSM #4 stated that they were new to the facility and the process they followed was to send a list of discharges to the ombudsman by email and they had been doing this since they started at the facility. She stated that they had been unable to find some notices from the former social worker but it looked like they were sending them monthly. She stated that she had been unable to find any written notices of transfer. She stated that at their former job they kept a binder with the copies of the notice of discharge or transfer and mailed them to the home addresses but they had been unable to find an original of the notice of discharge or transfer that the facility used.
On 9/21/2023 at approximately 1:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
3. For Resident #11 (R11), the facility staff failed to provide evidence that written notification of transfer was provided to the resident and/or responsible party for facility-initiated transfers on 6/11/2023 and 6/27/2023.
A review of R11's clinical record revealed the following progress notes:
- 6/11/2023 08:50 (8:50 a.m.) Note Text: EMS (emergency medical services) arrived on site, Pt (patient) being transported to hospital, unknown which hospital atm (at this moment).
- 6/14/2023 17:58 (5:58 p.m.) Admit Info: (R11) was admitted from Acute hospital via Stretcher for Seizures. Per Resident/Family the patient was admitted for : Seizures; Long Term Placement .
- 6/27/2023 16:32 (4:32 p.m.) . At 11:10 nurse came to me stating resident having a seizure. Nurse entered the room and resident laying on left side with full body shaking. Activity lasted for 8 mins. Resident not verbally responsive after the seizure with abnormal breathing. Sats (oxygen saturation) 88% on room air. Non-rebreather added. Resident sent to ER (emergency room) for full code status. (Name of provider), Hospice, and family notified.
- 7/4/2023 19:17 (7:17 p.m.) Admit Info: (R11) was admitted from Acute hospital via Stretcher for seizures activity. Per Resident/Family the patient was admitted for Long Term Placement .
Further review of the clinical record failed to reveal evidence that written notification of transfer was provided to the resident and/or responsible party for the transfer on 6/11/2023 and 6/27/2023.
On 9/20/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence that written notification of transfer was provided to the resident and/or responsible party for the transfer on 6/11/2023 and 6/27/2023 for R11.
On 9/21/2023 at approximately 8:00 a.m., ASM #1 stated that they did not have any evidence that written notification of transfer was provided to the resident and/or responsible party for the transfer on 6/11/2023 and 6/27/2023 for R11.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the nursing staff did not provide any written notification of transfer to the resident or the responsible party when they went to the hospital. She stated that they notified the family by telephone of the transfer.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN #3. LPN #3 stated that the nursing staff made a phone call to the family when the resident was transferred to the hospital but did not send a written notification of transfer. She stated that she thought that the social worker sent the written notification of transfer.
On 9/21/2023 at 9:48 a.m., an interview was conducted with OSM (other staff member) #4, the director of social services. OSM #4 stated that she had been unable to find any written notices of transfer. She stated that at their former job they kept a binder with the copies of the notice of discharge or transfer and mailed them to the home addresses but they had been unable to find an original of the notice of discharge or transfer that the facility used.
On 9/21/2023 at approximately 1:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided to the resident a...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided to the resident and/or responsible party (RP), when three out of 40 residents in the survey sample were transferred to the hospital; Residents #49, Resident #33, and Resident #11.
The findings include:
1. For Resident #49, the facility staff failed to evidence provision of bed hold notification to the resident and/or the responsible party at the time of transfer to the hospital on 7/19/23.
A review of Resident #49's eINTERACT (interventions to reduce acute care transfer) form dated 7/19/23 revealed, COPD, shortness of breath. Sent to hospital.
A review of the clinical record revealed there was no evidence that written bed-hold notice was provided to the resident and/or RP when Resident #49 was transferred to the hospital on 7/19/23.
An interview was conducted on 9/20/23 at 2:30 PM with LPN (licensed practical nurse) #2. When asked who provides bed hold notification upon transfer, LPN #2 stated, there is a form they are to send. When asked if there is evidence of the bed hold form sent. LPN #2 stated, no, they do not keep a copy of the form.
An interview was conducted on 9/21/23 at 9:48 AM with OSM (other staff member) #4, the director of social services. When asked who provides the bed hold notification, OSM #4 stated, there should be blank copies of the form at the nurse's station that are filled out with the price of the bed hold that is sent out with the resident, and then the family calls admission to reserve the bed hold. OSM #4 they did not know if nursing keeps a copy.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
A review of the facility's Bed Hold policy revealed Prior to initiated transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: The rights and limitations of the resident regarding bed-holds; reserve bed payment policy as indicated by the state plan (Medicaid residents); The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and The details of the transfer (per the notice of transfer).
No further information was provided prior to exit.
3. For Resident #33 (R33), the facility staff failed to provide evidence that bed-hold notice was provided to the resident and/or responsible party for a facility-initiated transfer on 7/29/2023.
A review of R33's clinical record revealed the following progress notes:
- 7/29/2023 07:52 (7:52 a.m.) N.O. (new order) received to send resident to ED (emergency department) r/t (related to) r (right) femur fx (fracture).
- 8/2/2023 15:30 (3:30 p.m.) Note Text: Readmit to facility from Acute Care Hospital for repair and treatment of right hip fracture. Surgical procedure was performed to right hip, dressing dry and intact, no bleeding .
Further review of the clinical record failed to reveal evidence that bed-hold notice was provided to the resident and/or responsible party for the transfer on 7/29/2023.
On 9/20/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of bed-hold notice provided to the resident and/or responsible party for the transfer on 7/29/2023 for R33.
On 9/21/2023 at approximately 8:00 a.m., ASM #1 stated that they did not have any evidence of bed-hold notice provided to the resident and/or responsible party for the transfer on 7/29/2023 for R33.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the nursing staff sent a bed-hold notice with the resident to the hospital upon transfer and that it should be documented in the progress notes.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN #3. LPN #3 stated that the nursing staff sent a bed hold notice with the resident at the time of transfer and documented it in the progress notes.
On 9/21/2023 at approximately 1:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
4. For Resident #11 (R11), the facility staff failed to provide evidence that bed-hold notice was provided to the resident and/or responsible party for facility-initiated transfers on 6/11/2023 and 6/27/2023.
A review of R11's clinical record revealed the following progress notes:
- 6/11/2023 08:50 (8:50 a.m.) Note Text: EMS (emergency medical services) arrived on site, Pt (patient) being transported to hospital, unknown which hospital atm (at this moment).
- 6/14/2023 17:58 (5:58 p.m.) Admit Info: (R11) was admitted from Acute hospital via Stretcher for Seizures. Per Resident/Family the patient was admitted for : Seizures; Long Term Placement .
- 6/27/2023 16:32 (4:32 p.m.) . At 11:10 nurse came to me stating resident having a seizure. Nurse entered the room and resident laying on left side with full body shaking. Activity lasted for 8 mins. Resident not verbally responsive after the seizure with abnormal breathing. Sats (oxygen saturation) 88% on room air. Non-rebreather added. Resident sent to ER (emergency room) for full code status. (Name of provider), Hospice, and family notified.
- 7/4/2023 19:17 (7:17 p.m.) Admit Info: (R11) was admitted from Acute hospital via Stretcher for seizures activity. Per Resident/Family the patient was admitted for Long Term Placement .
Further review of the clinical record failed to reveal evidence that bed-hold notice was provided to the resident and/or responsible party for the transfer on 6/11/2023 and 6/27/2023.
On 9/20/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence that bed-hold notice was provided to the resident and/or responsible party for the transfer on 6/11/2023 and 6/27/2023 for R11.
On 9/21/2023 at approximately 8:00 a.m., ASM #1 stated that they did not have any evidence that bed-hold notice was provided to the resident and/or responsible party for the transfer on 6/11/2023 and 6/27/2023 for R11.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the nursing staff sent a bed-hold notice with the resident to the hospital upon transfer and that it should be documented in the progress notes.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN #3. LPN #3 stated that the nursing staff sent a bed hold notice with the resident at the time of transfer and documented it in the progress notes.
On 9/21/2023 at approximately 1:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #49, the facility staff failed to complete an accurate MDS (minimum data set), a quarterly assessment for the us...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #49, the facility staff failed to complete an accurate MDS (minimum data set), a quarterly assessment for the use of oxygen.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/8/23, 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 MDS Section G-functional status coded the resident as requiring supervision for bed mobility, transfers and locomotion. A review of Section O: special procedures/treatments: coded the resident as oxygen- No.
A review of the comprehensive care plan dated 5/9/23, which revealed, FOCUS: The resident has altered respiratory status/difficulty breathing and COPD. INTERVENTIONS: OXYGEN SETTINGS: Bi-pap at night- FIO2 30 %.
A review of the physician orders dated 6/13/23 revealed, Bi-pap at night- FIO2 30% every evening and night shift for sob (shortness of breath). Bi-pap keep covered when not in use, every day shift.
On 9/21/23 at 11:20 AM, an interview was conducted with RN (registered nurse) #5, the MDS coordinator. Asked to review Resident #49's MDS Section O dated 8/8/23 and the orders for bi-pap, RN #5 stated, Yes, this is coded incorrectly, I will modify this. We use the RAI (resident assessment instrument) as our standard.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
According to the RAI (resident assessment instrument) MDS Section O: 0100C, Oxygen therapy: Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula.
No further information was provided prior to exit.
Based on observations, resident interview, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for three of 40 residents in the survey sample, Residents #62, #33 and #49.
The findings include:
1. For Resident #62 (R62), the facility staff failed to code the annual MDS assessment for current tobacco use.
On the most recent MDS assessment, an annual assessment, with an ARD (assessment reference date) of 6/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. Section J documented no current tobacco use.
On 9/19/2023 at 3:56 p.m., an interview was conducted with R62. R62 stated that they had smoked for years and had been smoking at the facility since admission. R62 stated that the facility stored their cigarettes and lighter in a box that they took at during the smoking times.
The comprehensive care plan for R62 documented in part, History of smoking and current smoker
Date Initiated: 12/06/2019. Revision on: 08/09/2023.
The Smoking-Resident Safety Evaluation for R62 dated 2/9/2023 documented in part, .Tobacco Utilization: 1. Does the resident use tobacco products? Yes. Does the facility allow smoking? Yes. Tobacco products utilized: Cigarettes/Cigars .
On 9/20/2023 at 2:34 p.m., an interview was conducted with RN (registered nurse) #5, MDS coordinator. RN #5 stated that when completing the tobacco use section on the MDS assessment they reviewed the care plan and clinical record to see if the resident smoked. She reviewed R62's care plan and stated that there was a care plan for smoking and stated that she was not sure why it was not coded for tobacco use.
According to the RAI (resident assessment instrument) Manual, Version 1.16, dated October 2018, section J1300 documented in the steps for assessment, 1. Ask the resident if he or she used tobacco in any form during the 7-day look-back period. 2. If the resident states that he or she used tobacco in some form during the 7-day look-back period, code 1, yes .
On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
2. For Resident #33 (R33), the facility staff failed to assess the mental status on the MDS (minimum data set) assessment.
On the most recent MDS, a significant change assessment with an ARD (assessment reference date) of 8/10/2023, R33 was coded in Section B - Hearing, Speech and Vision as usually understanding others and being understood. In Section C - Cognitive Patterns, the resident interview was not completed. The resident and/or staff assessment were blank.
The nursing admission assessment dated [DATE] documented R33 not having dementia or other cognitive deficits that make them unable to answer questions.
On 9/20/2023 at 2:34 p.m., an interview was conducted with RN (registered nurse) #5, MDS coordinator. RN #5 stated that Section C of the MDS was normally completed by the social worker but they had completed at times when the social worker position was not filled. She stated that she interviewed the resident and attempted to complete the assessment on all residents. She stated that if she was unable to complete the assessment on the resident then the staff assessment was completed. She reviewed R33's significant change assessment with the ARD of 8/10/2023 and stated that the social worker would have been responsible for completing it and that it looked like it was not done.
On 9/21/2023 at 9:48 a.m., an interview was conducted with OSM (other staff member) #4, the director of social services. OSM #4 stated that they were responsible for completing Section C of the MDS assessment. She stated that when it was due, she typically printed out a paper copy and completed it with the resident and then transferred it to the MDS. She stated that if the resident was able to speak or understand they did the resident assessment and if not they did the staff assessment so one or the other should be completed for everyone. She reviewed R33's significant change MDS with the ARD of 8/10/2023 and stated that they had started working at the facility that week and it may not have been them completing assessments that week but it should have been completed.
According to the RAI (resident assessment instrument) Manual, Version 1.16, dated October 2018, section C0100 documented in 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) and is not contingent
upon item B0700, Makes Self Understood .
On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facilit...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to develop and/or implement a baseline care plan for three of 40 residents in the survey sample, Residents #119, #120 and #96.
1. For Resident #119, the facility failed to implement the baseline care plan for pre and post dialysis weights.
Resident #119 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and dialysis.
A review of the baseline care plan dated 9/9/23 revealed, FOCUS: The resident has ESRD and receives Hemodialysis on Tuesday/Thursday/Saturday (T-TH-SA). INTERVENTIONS: Pre-Post dialysis weights. Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols.
A review of the physician's order dated 9/12/23 revealed, Dialysis every T-TH-SA. Obtain pre-dialysis vital signs, and weight - input weight from dialysis communication forms every evening shift every Tue, Thu, Sat. Obtain post-dialysis vital signs, and weight - input weight from dialysis communication forms every evening shift every Tue, Thu, Sat.
A review of Resident #119's TAR (treatment administration record) for September 2023 revealed, pre-dialysis weights were not obtained on 9/19/23 and post-dialysis weights were not obtained on 9/12/23, 9/14/23 and 9/16/23.
An interview was conducted on 9/20/23 at 8:40 AM with Resident #119, and when asked if he was weighed before and after dialysis, Resident #119 stated, no, not always.
An interview was conducted on 9/20/23 at 8:00 AM with RN #2. When asked the purpose of the dialysis communication form, RN #2 stated, the purpose is to share and receive information with the dialysis center, including vital signs, weights, medications and any lab results. When asked to review Resident #119's TAR for pre and post dialysis weights, RN #2 stated the weights were not there and the the care plan was not implemented.
On 9/20/23 at 3:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant, were made aware of the findings.
A review of the facility's Care Planning-Person Centered revealed, A baseline care plan to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Baseline Care Plan: is a care plan developed within 48 hours of admission to include minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders. Physician orders.
No further information was provided prior to exit.
2. For Resident #120, the facility failed to implement the baseline care plan for the use of a dignity bag (cover) for an indwelling urinary catheter, and failed to develop a baseline care plan for the use of the anticoagulant medication, Warfarin.
Observations of Resident #120's urinary catheter bag revealed there was no privacy covering on 9/19/23 at 1:40 PM and 2:45 PM, 9/20/23 at 8:10 AM and 9/20/23 at 4:15 PM. The urinary catheter bag was visible from the resident's doorway.
A review of the baseline care plan dated 9/14/23 included, FOCUS: The resident has Indwelling Catheter:
history of BPH. INTERVENTIONS: The resident has 16 FR/10cc Position catheter bag and tubing below
the level of the bladder and away from entrance room door. Dignity bag to cover drainage bag content.
A review of the physician orders dated 6/13/23 included, Foley Catheter: (16 French) Balloon Size: (10 milliliters) For Diagnosis of BPH every shift.
A review of the physician orders dated 6/13/23 included, Warfarin Sodium Tablet 2.5 milligram (MG) Give 1 tablet by mouth one time a day for treating/preventing blood clots.
On 9/20/23 at 8:10 AM an interview was conducted with RN (registered nurse) #2. When asked if a urinary catheter bag has no privacy covering, is the resident's care plan implemented, RN #2 stated, No, it is not. The privacy covering should be on the bag.
On 9/21/23 at 9:15 AM an interview was conducted with LPN (licensed practical nurse) #3. When asked if a resident's baseline care plan should include an anticoagulant warfarin, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, to assess for signs and symptoms of bleeding, labs like PT (prothrombin time) and INR (international normalized ratio) and monitoring their diet.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
No further information was provided prior to exit.
3. For Resident #96 (R96), the facility staff failed to implement the baseline care plan for pressure injury assessment, treatment, and documentation.
R96 was admitted to the facility on [DATE] with a diagnosis of a stage three pressure injury of the sacral region (1). R96's care plan dated 9/6/23 documented, I have actual impairment to skin integrity r/t (related to) (Sacrum) Immobility. Administer medications, supplements and treatments as ordered .Assess/Monitor/Document wound: size, depth, margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis per facility protocols .
A review of R96's clinical record revealed a physician's order dated 9/8/23 to cleanse the sacral wound with wound cleanser. Apply calcium alginate (used to treat wounds) to wound bed and cover with foam dressing every day shift. A review of R96's September 2023 TARs (treatment administration records) revealed the same physician's order but failed to reveal documentation that the treatment was completed on 9/8/23, 9/10/23, 9/11/23, 9/14/23 and 9/15/23. The spaces for nurses to sign off the treatments had been done were blank. A review of nurse's notes for all dates also failed to reveal documentation that the treatments were completed.
Further review of R96's clinical record revealed a weekly skin observation dated 9/11/23 that documented, Open area and Cleanse sacral wound with wound cleanser. Apply calcium alginate to wound bed cover with foam dressing. A weekly skin observation dated 9/19/23 documented, admitted with open area to sacrum. The weekly skin observations failed to document a description of the pressure injury (including stage, measurements, presence or absence of any tunneling or undermining, type of tissue, or presence or absence and type of drainage) and progress in wound healing.
On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident's skin. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record.
On 9/21/23 at 9:16 a.m., another interview was conducted with LPN #3. LPN #3 stated, The purpose of the care plan is the action of the care while they [the residents] are here. In regard to care plan implementation, LPN #3 stated the nurses have access to the care plans and the mds (minimum data set) staff is available if nurses have questions about the care plan.
On 9/21/23 at 1:28 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) Stage 3 Pressure Injury: Full-thickness skin loss.
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and
epibole (rolled wound edges) are often present. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to review and revise the care plans for three of 40 residents in the sur...
Read full inspector narrative →
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to review and revise the care plans for three of 40 residents in the survey sample, Residents #13, 108 and #83.
The findings include:
1. For Resident #13 (R13), the facility staff failed to review and revise the comprehensive care plan after a resident to resident altercation on 8/21/2023.
On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 6/24/2023, the resident scored 6 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented no behaviors other than rejection of care.
The progress notes for R13 documented in part,
- 8/21/2023 13:23 (1:23 p.m.) Note Text : Resident got into a physical altercation with another resident in resident's room. As a result this resident received a contusion to
the right eye. Resident was medicated with Tylenol for pain. Resident alert and verbal. able to make all his needs known. Currently up in his wheelchair visiting. No s/s (signs/symptoms) of distress at this time.
- 8/21/2023 13:50 (1:50 p.m.) Note Text : SW (social worker) spoke with resident regarding incident in facility, resident stated he was agitated due to other's resident's attitude towards him and resident came into his space to hit him in the face. SW explained that the residents will need to be separated, and physical violence is not allowed in the facility at any time. Nursing completed skin check and injuries sustained, appropriate follow up concluded. Mother was called regarding matter, resident interview complete. Mother spoke with admin (administrator), DON (director of nursing), and SW about incident, police were called and no charges made.
Review of the facility investigation dated 8/21/2023 documented a summary of the incident, resident statements, nursing notes, and social services notes.
The comprehensive care plan for R13 failed to evidence a review or revision related to the resident to resident altercation on 8/21/2023.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to document and keep track of the residents care while at the facility. She stated that the nurses and MDS reviewed and revised the care plan.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN #3. LPN #3 stated that the purpose of the care plan was to provide an action of care for the resident. She stated that the comprehensive care plan was completed by MDS. She stated that the care plan should be revised after a resident to resident altercation so the staff knew the behaviors occurred.
On 9/21/2023 at 9:48 a.m., an interview was conducted with OSM (other staff member) #4, the director of social services. OSM #4 stated that when a resident to resident altercation occurred they interviewed the residents, made sure nursing did a physical assessment and discussed a room change if needed to make sure the residents were kept safe. She stated that social services may update the care plan if the altercation was physical because of the aggressive behaviors. She stated that the care plan would be updated for both residents.
The facility policy, Care Planning- Comprehensive Person-Centered undated, documented in part, . 13. The comprehensive care plan will: a. Incorporate identified problem areas . 15. Behavior Intervention Plan (BIP) may be developed when a resident exhibits behaviors that place the resident, other residents, or staff at risk or impedes on their rights. a.
The BIP will be developed in collaboration with the resident, interdisciplinary team, and mental health professionals as appropriate. b. The BIP will be incorporated into the resident's comprehensive care plan. i.
The BIP will be reviewed and updated as needed to address change in the resident behaviors. c. The BIP will clearly identify the behaviors being addressed, interventions/approaches to reduce behaviors, and expected outcomes. The BIP will also include consequences and action that may be taken should the resident not comply with the agreed expectations .
On 9/21/2023 at 1:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was obtained prior to exit.
2. For Resident #108 (R108), the facility staff failed to review and revise the resident's comprehensive care plan after a physical altercation with another resident on 8/21/23.
A review of R108's clinical record revealed a progress note dated 8/21/23 that documented, Resident was involved in a resident on resident altercation this afternoon. According to (R108), the other resident involved slapped him on his upper shoulder/chest area after a verbal altercation took place and, in relation, (R108) hit the other resident in the face. (R108) obtained minor scratches, delivered by other resident, during the scuffle. He was bleeding from one scratch on his left forearm and had a 2-3 inch scratch on his left upper arm. The superficial wounds were cleaned but did not need to be dressed. His RP (responsible party)/Emergency Contact (mother) was contacted by this nurse and the situation was explained to her. She expressed no concerns at that time. Both residents are being observed to help prevent further issues.
A review of R108's comprehensive care plan revised on 8/29/23 failed to reveal the care plan was reviewed and revised regarding the physical altercation.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated, The purpose of the care plan is the action of the care while they [the residents] are here. LPN #3 stated residents' care plans should be reviewed and revised after a physical altercation, so employees know the residents have a behavior.
On 9/21/23 at 1:28 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
3. For Resident #83 (R83), the facility staff failed to review and revise the resident's comprehensive care plan for the resident's use of the anti-anxiety medication, diazepam.
A review of R83's clinical record revealed a physician's order dated 8/4/23 for diazepam (1) 5 mg (milligrams)- one tablet by mouth every eight hours as needed for 180 days for anxiety. A review of R83's August 2023 and September 2023 MARs (medication administration records) revealed the resident was administered as needed diazepam 28 times in August 2023 and 24 times in September 2023. A review of R83's comprehensive care plan revised on 8/15/23 failed to reveal the care plan was reviewed and revised for the resident's use of anti-anxiety medication.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated, The purpose of the care plan is the action of the care while they [the residents] are here. LPN #3 stated residents' care plans should be reviewed and revised for the use of anti-anxiety medication so staff can monitor for behaviors and changes in behaviors.
On 9/21/23 at 1:28 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) Diazepam is used to treat anxiety. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682047.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
Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for two of 40 residents in the survey...
Read full inspector narrative →
Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for two of 40 residents in the survey sample, Residents #106 and #219.
The findings include:
1.a. For Resident #106 (R106), the facility staff failed to obtain a physician's order for pressure injury treatments that were completed.
A review of R106's clinical record revealed nurses' notes that documented the following:
-5/22/23 It was reported by therapy that resident has large ulcers on heels. On arrival resident has unstageable ulcers (injuries) (1) on both heels and stage 1 (1) ulcer on both side of the foot and ankle. Wiped down with skin prep.
-6/7/23 Resident was noted to have an unstageable ulcer (pressure injury) measuring 7 cm (centimeters) x 10 cm in circumference in the sacrum. 5 cm x 7 cm stage II (1) ulcer on the lateral aspect of the left upper thigh, fluid filled in the center and surrounding tissues red and irritated. 4 cm x 4.5 cm unstageable ulcer on both heels. Scattered bruises on the left lower leg and foot. Sacral and left hip wound were cleansed with wound cleanser and dry dressing applied.
Further review of R106's clinical record failed to reveal the nurses' obtained physician's orders for the above treatments that were completed.
On 9/20/23 at 10:10 a.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated the doctor has to give orders for how to clean wounds.
On 9/21/23 at 1:28 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 and Treatment Orders documented, 1. Medications will be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.
Reference:
(1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a
bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear .
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin.
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister .
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss.
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue) . This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
1.b. For Resident #106 (R106), the facility staff failed to accurately document a resident's refusal of a skin assessment upon admission. Instead, the nurse documented the resident presented with no skin issues.
R106's admission screener (assessment) dated 5/18/23 documented the resident had no skin issues. A physical therapy note dated 5/19/23 documented R106 presented with unstageable pressure injuries (1) on both heels.
On 9/20/23 at 10:10 a.m., an interview was conducted with RN #4 (the nurse who documented the admission screener assessment). RN #4 stated R106 refused a skin assessment on the day of admission, but per the report she received from the transferring facility, the resident did not have skin issues, so she documented no skin issues on the admission assessment. RN #4 stated that instead of documenting no skin issues, she should have documented R106 refused the skin assessment on 5/18/23.
On 9/21/23 at 1:28 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, Documentation of Wound Treatments documented, 1. Wound assessments are documented upon admission .
Reference:
(1) Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss.
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue) . This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
2. For Resident #219 the facility staff failed to administer four medications as ordered by the physician.
A review of the physician's orders revealed the following:
(1) Aspirin an 81 mg (milligrams) tablet once daily. Order dated 9/8/23.
(2) Valsartan an 80 mg tablet once daily. Order dated 9/8/23.
(3) Vitamin D3 a 25 mcg (micrograms) tablet. Give two tablets once daily. Order dated 9/9/23.
(4) Zinc a 220 mg tablet once daily for wound healing. Order dated 9/13/23.
On 9/20/23 at 9:05 AM, the medication administration was conducted with LPN #10 (Licensed Practical Nurse), for Resident #219. Upon review of the physician's orders and the Medication Administration Record (MAR) for September 2023 revealed that the Aspirin, Valsartan, Vitamin D3 and Zinc were ordered but were not prepared and administered on observation. They were signed out as being administered.
On 9/20/23 at 1:10 PM, an interview was conducted with LPN #10. She stated that she thought she pulled and administered the above medications, and is why they were signed out as being administered. She stated that she did not know how she missed them.
On 9/20/23 at 1:50 PM, a second follow up interview was conducted with LPN #10. She stated that the process for medication administration included the five rights of making sure you have the right dose, right time, right route, right resident and the right medication. She stated that since there were medications that were missed, the five rights were not followed.
The facility policy Adverse Consequences and Medication Errors documented, Medication Error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services 5. Examples of medications errors include: a. omission - a drug is ordered but not administered; b. unauthorized drug - a drug is administered without a physician's order; c. wrong dose . d. wrong route of administration . e. wrong dosage form . f. wrong drug . g. wrong time; and/or; h. failure to follow manufacturer instructions and/or accepted professional standards .
On 9/20/23 at 3:30 PM, an end-of-day meeting was conducted with ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #4, the Regional Nurse Consultant, were made aware of the findings. No further information was provided by the end of the survey.
References:
(1) Aspirin - Is used to prevent heart attacks, strokes, and reduce the risk of death from a heart attack or stroke.
Information obtained from https://medlineplus.gov/druginfo/meds/a682878.html
(2) Valsartan - Is used alone or in combination with other medications to treat high blood pressure.
Information obtained from https://medlineplus.gov/druginfo/meds/a697015.html
(3) Vitamin D3 - Is used as a dietary supplement when the amount of vitamin D in the diet is not enough .is also used along with calcium to prevent and treat bone diseases .
Information obtained from https://medlineplus.gov/druginfo/meds/a620058.html
(4) Zinc - Is an essential trace element commonly found in red meat, poultry, and fish. It is necessary in small amounts for human health, growth, and sense of taste. Zinc is found throughout the body. The body doesn't store excess zinc, so it must be obtained from the diet. It's needed for immune function, wound healing, blood clotting, thyroid function, and much more. It also plays a key role in maintaining vision and might have effects against viruses.
Information obtained from https://medlineplus.gov/druginfo/natural/982.html)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility failed to implement interventions to maintain a safe smoking environment for Resident #101.
Resident #101 was ad...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility failed to implement interventions to maintain a safe smoking environment for Resident #101.
Resident #101 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes,
left hemiplegia and, nicotine dependence.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/27/23, 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 MDS Section G-functional status coded the resident as requiring supervision for transfers and locomotion.
A review of the comprehensive care plan dated 8/9/23, which revealed, FOCUS: The resident is a smoker.
INTERVENTIONS: Instruct resident about the facility policy on smoking: locations, times, safety
concerns. Instruct resident about smoking risks and hazards and about smoking cessation. aids that are available.
A review of the Resident Safety Evaluation dated 8/25/23, revealed Smoking Safety Evaluation: Poor vision or blindness-no, Balance problems while sitting or standing-no, Total or limited ROM in arms or hands-no, Insufficient fine motor skills needed to securely hold-no, Lethargic / falls asleep easily during tasks or activities-no, Burns skin, clothing, furniture or other-no, Drops ashes on self-no, Follow the facility's policy on location and time of smoking-yes. Concerns: Unable to light a cigarette safely-no, Unable to hold a cigarette safely-no, Unable to extinguish a cigarette safely-no, Unable to use ashtray to extinguish a cigarette-no. Review and Plan: Is the resident a safe smoker? Safe to smoke with supervision.
On 9/19/23 at 2:25 PM, Resident #101 was observed leaving her room in a wheelchair, self-propelled, with a cigarette tucked in her right foot sock. Resident #101 was asked where she obtained the cigarette and she stated, it is in my sock and would not provide any further information.
An interview was conducted on 9/19/2023 at 2:50 PM with RN (registered nurse) #1. Asked to describe the smoking process, RN #1 stated, You heard me asking the residents why they had their cigarettes and lighters. Normally the CNA's (certified nursing assistants) monitor smoking. I do not think that they are supposed to have their cigarettes and lighters. RN #1 stated, When residents are admitted they have a form they are given they have to sign and the doctor has to sign about smoking. The smoking box is new, we have had it a couple of weeks. I never monitored smoking prior to them putting the box in place. We have this box for the cigarettes and lighters, not all the residents put them in here. They are supposed to and I do not believe that any resident should have their cigarettes or lighters.
On 9/19/23 at 3:55 PM, an observation was made of Resident #101 smoking. She entered the smoking area with a cigarette in her right hand and another resident was observed passing a lighter to Resident #101, who then lit her own cigarette.
An interview was conducted on 9/19/23 at 4:00 PM with CNA #1. Asked to describe the smoking process, CNA #1 stated, this is a new box. It replaced the older box we had. The residents are to have their lighters and cigarettes in this box. They do not always follow the rules. The box is then kept in the locked med room behind the nurse's station.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
No further information was provided prior to exit.
Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement a safe smoking environment for three out of 40 residents in the survey sample, Residents #13, #62 and #101.
The findings include:
1. For Resident #13 (R13), the facility staff failed to secure smoking materials observed carried by R13 during observations on 9/19/2023.
On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 6/24/2023, the resident scored 6 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions.
On 9/19/2023 at 2:30 p.m., an observation was made of R13 in the facility courtyard smoking. R13 was observed lighting their cigarette using a lighter that they removed from their pocket of the cargo shorts they were wearing and returning the lighter to the pocket. The supervising staff member was heard asking R13 if they needed a light for the cigarette in which R13 stated that they had one. R13 was observed returning into the facility at the end of the break with the lighter in their shorts pocket.
On 9/19/2023 at 4:30 p.m., an additional observation was conducted of R13 in the facility courtyard smoking. R13 was observed smoking during the supervised smoke break using a lighter that they removed from their shorts pocket and was observed sharing the lighter with another resident to light their cigarette and returning the lighter to their shorts pocket. R13 was observed to return to the facility at the end of the break with the lighter in their shorts pocket. The supervising staff member was observed directly in front of R13 talking to the residents during the smoke break.
On 9/20/2023 at 9:09 a.m., an interview was conducted with R13. R13 stated that they currently smoked. When asked about their cigarettes and lighter, R13 stated that the nurses kept everything at the desk.
The comprehensive care plan for R13 documented in part, (R13) is a smoker. Date Initiated: 03/17/2023. Revision on: 08/09/2023.
The clinical record documented a smoking resident safety evaluation for R13 dated 3/22/2023 which documented the resident able to smoke with supervision.
On 9/19/2023 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that the CNA's (certified nursing assistants) normally supervised the smoke breaks at the facility and they were filling in for the 2:30 p.m. break because they were busy. He stated that he did not think that residents were supposed to have cigarettes or lighters on them and he thought that all smoking materials were supposed to be kept in the smoking box at the nurses station that they brought out during breaks. He stated that he had asked some of the residents he observed outside at the 2:30 p.m. break why they had the cigarettes and lighters and was not sure of the process. He stated that he thought the smoking box process was new and they had it for a couple of weeks now.
On 9/19/2023 at 3:45 p.m., an interview was conducted with CNA #11. CNA #11 stated that there were scheduled smoking times and the residents met in the room by the courtyard and the staff took them outside for breaks. She stated that they kept a locked box for the lighters and cigarettes and they passed out the cigarettes as the residents went out the door and then they lit them for the residents. She stated that this had been the process for the past two years she had worked there. She stated that she was aware of residents that did sneak in lighters and cigarettes and if they saw them, they were supposed to confiscate them because they were not allowed to keep them on their person. She stated that residents in the facility were not allowed to keep any smoking materials in their rooms.
On 9/19/2023 at 4:51 p.m., an interview was conducted with CNA #1. CNA #1 stated that residents were not supposed to have lighters or cigarettes on them and they were supposed to have all smoking materials in the smoking box that was locked at the nurses station. She stated that she was aware that some residents had lighters and they were not supposed to have them.
The facility policy Smoking Permitted revised 10/20/22 documented in part, The facility will implement processes to respect the resident's right to smoke and will provide an environment for safe smoking in a manner that does not infringe on any resident's rights . Residents who desire to smoke may not keep smoking related materials [i.e. cigarettes, electronic smoking devices (e-cigarettes), refill cartridges/fluid, cigars, pipes, tobacco, lighter, lighter fluid, match, etc.] on their person when not smoking or in their room. a. For safety purposes, all smoking related materials, devices and tobacco products must be stored in a safe place in the facility, such as the nurses station .Protective equipment to promote safe smoking will be offered as appropriate based on resident assessment and the resident will be encouraged and assisted as necessary in using the protective devices .
On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was obtained prior to exit.
2. For Resident #62 (R62), the facility staff failed to provide a cigarette extender and smoking apron for use while smoking.
On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 6/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. Section J documented no current tobacco use.
On 9/19/2023 at 2:30 p.m., an observation was made of R62 in the facility courtyard smoking. R62 was observed smoking two cigarettes during the supervised smoke break without using a cigarette extender or smoking apron.
On 9/19/2023 at 3:56 p.m., an interview was conducted with R62. R62 stated that they had smoked for years and had been smoking at the facility since admission. R62 stated that the facility stored their cigarettes and lighter in a box that they took at during the smoking times. R62 stated that they had a cigarette extender that they kept in their room and they took it outside sometimes. R62 stated that the facility used to require them to use smoking aprons at one time but they were not required anymore.
On 9/19/2023 at 4:30 p.m., an additional observation was conducted of R62 in the facility courtyard smoking. R62 was observed smoking during the supervised smoke break without using a cigarette extender or smoking apron.
The comprehensive care plan for R62 documented in part, History of smoking and current smoker
Date Initiated: 12/06/2019. Revision on: 08/09/2023. Under Interventions it documented in part, Assist/ensure cigarette extender is used during designated smoke times. Date Initiated: 03/29/2022. Revision on: 01/11/2023 . Provide with a smoking apron and assist to put on. Date Initiated: 02/19/2020. Revision on: 01/11/2023 .
The Smoking-Resident Safety Evaluation for R62 dated 2/9/2023 documented in part, .Tobacco Utilization: 1. Does the resident use tobacco products? Yes. Does the facility allow smoking? Yes. Tobacco products utilized: Cigarettes/Cigars . Resident adaptive equipment needs: a. Smoking apron, b. Cigarette holder, c. Supervision .
On 9/19/2023 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that the CNA's (certified nursing assistants) normally supervised the smoke breaks at the facility and they were filling in for the 2:30 p.m. break because they were busy.
On 9/19/2023 at 3:45 p.m., an interview was conducted with CNA #11. CNA #11 stated that residents met in the room by the courtyard prior to going out to smoke at the scheduled times and were supposed to put on smoking aprons prior to going out if they required them. She stated that she knew which residents required smoking aprons because she worked with them so often. She stated that she knew that R62 had a cigarette extender that they kept in their room to bring with them. She stated that the staff should offer to apply smoking aprons to any residents who required them and if they refused report it to the nurse.
On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5% for one o...
Read full inspector narrative →
Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5% for one of 40 residents in the survey sample; Resident #219. During the Medication Administration task, out of 29 opportunities, the facility failed to administer four medications, resulting in an error rate of 13.79%.
The findings include:
For Resident #219 the facility failed to administer four medications during the medication administration task.
On 9/20/23 at 9:05 AM, the medication administration was conducted with LPN #10 (Licensed Practical Nurse), for Resident #219. Upon review of the physician's orders (below) and the Medication Administration Record (MAR) for September 2023 revealed that four medications were ordered but were not prepared and administered on observation. They were signed out as being administered.
A review of the physician's orders revealed the following:
(1) Aspirin an 81 mg (milligrams) tablet once daily. Order dated 9/8/23.
(2) Valsartan an 80 mg tablet once daily. Order dated 9/8/23.
(3) Vitamin D3 a 25 mcg (micrograms) tablet. Give two tablets once daily. Order dated 9/9/23.
(4) Zinc a 220 mg tablet once daily for wound healing. Order dated 9/13/23.
On 9/20/23 at 1:10 PM, an interview was conducted with LPN #10. She stated that she thought she pulled and administered the above medications, and is why they were signed out as being administered. She stated that she did not know how she missed them.
On 9/20/23 at 1:50 PM, a second follow up interview was conducted with LPN #10. She stated that the process for medication administration included the five rights of making sure you have the right dose, right time, right route, right resident and the right medication. She stated that since there were medications that were missed, the five rights were not followed.
The facility policy Adverse Consequences and Medication Errors documented, Medication Error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services 5. Examples of medications errors include: a. omission - a drug is ordered but not administered; b. unauthorized drug - a drug is administered without a physician's order; c. wrong dose . d. wrong route of administration . e. wrong dosage form . f. wrong drug . g. wrong time; and/or; h. failure to follow manufacturer instructions and/or accepted professional standards .
On 9/20/23 at 3:30 PM, an end-of-day meeting was conducted with ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #4, the Regional Nurse Consultant, were made aware of the findings. No further information was provided by the end of the survey.
References:
(1) Aspirin - Is used to prevent heart attacks, strokes, and reduce the risk of death from a heart attack or stroke.
Information obtained from https://medlineplus.gov/druginfo/meds/a682878.html
(2) Valsartan - Is used alone or in combination with other medications to treat high blood pressure.
Information obtained from https://medlineplus.gov/druginfo/meds/a697015.html
(3) Vitamin D3 - Is used as a dietary supplement when the amount of vitamin D in the diet is not enough .is also used along with calcium to prevent and treat bone diseases .
Information obtained from https://medlineplus.gov/druginfo/meds/a620058.html
(4) Zinc - Is an essential trace element commonly found in red meat, poultry, and fish. It is necessary in small amounts for human health, growth, and sense of taste. Zinc is found throughout the body. The body doesn't store excess zinc, so it must be obtained from the diet. It's needed for immune function, wound healing, blood clotting, thyroid function, and much more. It also plays a key role in maintaining vision and might have effects against viruses.
Information obtained from https://medlineplus.gov/druginfo/natural/982.html)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and facility document review, the facility staff failed to store medications safely in one of three medication carts.
The findings include:
On 12/13/23 at 9:19 a....
Read full inspector narrative →
Based on observation, staff interview and facility document review, the facility staff failed to store medications safely in one of three medication carts.
The findings include:
On 12/13/23 at 9:19 a.m., an observation of the medication cart used during medication administration revealed one bottle each of Acetaminophen 500mg (milligrams), Multi-Vitamins, and Vitamin C 1000mg on the top of the medication cart, unsecured. There were no staff members within sight of the medication cart.
On 12/13/23 at 9:25 a.m., LPN (licensed practical nurse) #3 was interviewed when she returned to the medication cart. She stated that she placed the medications on the cart because she was going to refill the cart after she came back to it. She stated she should not have left the medications unattended on the top of the cart.
On 12/13/23 at 11:11 a.m., LPN#1 was interviewed. She stated that it is not okay for any types of medications to be on top of the medication cart, especially if the nurse is not around. She also stated, The medication cart is not supposed to be left unattended because patients can grab medications or knock them over.
On 12/13/2023 at 12:01 p.m., ASM (administrative staff member) #1, the administrator; ASM#2, the director of nursing; and ASM#3 the regional director of clinical service were informed of these concerns.
A review of the facility's policy, Medication Storage revealed, in part: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
No further information was provided 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
Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to obtain ordered laboratory testing for one of 40 r...
Read full inspector narrative →
Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to obtain ordered laboratory testing for one of 40 residents in the survey sample, Resident #53.
The findings include:
For Resident #53 (R53), the facility staff failed to obtain a stool culture as ordered on 9/14/2023.
On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/5/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions.
On 9/19/2023 at 12:04 p.m., an interview was conducted with R53. R53 stated that they had been sick off and on for about 16 days with heartburn, nausea and abdominal pain. R53 stated that they had an x-ray done and had seen the doctor once and the nurse practitioner a couple of times. R53 stated that they were concerned that they were being brushed off because they still had times when they felt bad and didn't know what the next step was.
The physician orders for R53 documented in part, Obtain stool culture one time only for c-diff (1) for 2 days. Order Date: 09/14/2023.
The eTAR (electronic treatment administration record) for R53 dated 9/1/2023-9/30/2023 failed to evidence collection of the stool specimen ordered on 9/14/2023.
The progress notes documented in part, 9/14/2023 14:10 (2:10 p.m.) Physician/NP progress note. Member c/o (complains of) abdominal pain and 2 loose stools. NP (nurse practitioner) ordered stool culture and KUB (x-ray). NP encouraged member to take medications as prescribed member verbalized understanding.
The clinical record failed to evidence documentation of the stool culture being obtained or sent to the lab. The clinical record further failed to evidence documentation of notification of the physician and/or the nurse practitioner of the stool specimen not being collected.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they had looked for the results of the ordered stool culture and did not find anything and they were going to follow up with the other nurses and the nurse practitioner.
On 9/21/2023 at 11:07 a.m., LPN #3 stated that they had spoken with the nurse practitioner and she had canceled the order for the stool culture due to the resident no longer having any diarrhea. She stated that the order was canceled 9/21/2023 and she would have expected nursing to have addressed the stool culture not having been obtained prior to today.
On 9/21/2023 at 11:41 a.m., an interview was conducted with ASM (administrative staff member) #5, nurse practitioner. ASM #5 stated that they had examined R53 last on 9/15/2023 and reviewed the x-ray results with them then. She stated that she had examined them prior to that for complaints of abdominal pain and diarrhea when she had ordered an x-ray and stool culture. She stated that as of the last examination R53 had not complained of any pain and had not reported any new concerns to the staff.
The facility policy, Lab and Diagnostic Test Results documented in part, .1. The physician/practitioner will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests as ordered .
On 9/21/2023 at 1:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0840
(Tag F0840)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis ag...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for two of 40 residents in the survey sample, Resident #119 and #83.
The findings include:
1. For Resident #119, the facility failed to evidence a written dialysis agreement with a dialysis center, .
Resident #119 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), and dialysis.
A review of the comprehensive care plan dated 9/9/23 which revealed, FOCUS: The resident has ESRD and receives Hemodialysis on Tuesday/Thursday/Saturday (T-TH-SA). INTERVENTIONS: Pre-Post dialysis weights. Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols.
A review of the physician's order dated 9/12/23 revealed, Dialysis every T-TH-SA.
During the entrance conference to the facility on 9/19/23, a request was made for the dialysis contracts or agreements.
On 9/20/23 at 12:37 PM, ASM (administrative staff member) #1, the administrator, stated, We do not have the dialysis contract and we have been working with them to get us one. We have the old contract from the previous company but do not have one for the dialysis centers under our corporation. When asked the effective date of the new corporation, ASM #1 stated it was 12/19/22.
On 9/20/23 at 3:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant, were made aware of the findings.
A review of the facility's End Stage Renal Disease-Care of the Patient policy, revealed, Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to:
a. the development of a comprehensive and integrated care plan
b. the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination, and collaboration.
c. timely medication administration
d. advance directives and code status
e. nutritional and fluid management
f. provision and documentation of appropriate access care
g. hemodialysis treatment days and times
No further information was provided prior to exit.
2. For Resident #83, the facility failed to evidence a written dialysis agreement with a dialysis center.
Resident #83 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), and dialysis.
A review of the comprehensive care plan dated 9/9/23 which revealed, FOCUS: The resident has ESRD and receives Hemodialysis on (M,W,F). INTERVENTIONS: Pre-Post dialysis weights. Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols.
A review of the physician's order dated 6/5/23 revealed, Dialysis every Monday, Wednesday, and Friday at 11:45 AM.
During the entrance conference to the facility on 9/19/23, a request was made for the dialysis contracts or agreements to be provided.
On 9/20/23 at 12:37 PM, ASM (administrative staff member) #1, the administrator, stated, We do not have the dialysis contract and we have been working with them to get us one. We have the old contract from the previous company but do not have one for the dialysis centers under our corporation. When asked the effective date of the new corporation, ASM #1 stated it was 12/19/22.
On 9/20/23 at 3:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant, 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facilit...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to follow infection control practices for two of 40 residents in the survey sample, Resident #49 and #120.
The findings include:
1. Resident #49's bi-pap mask was observed on top of Resident #49's bed partially covered with a blanket and clothing, on 9/19/23 at 1:00 PM and 9/20/21 at 11:05 AM.
Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes, congestive heart failure, COPD (chronic obstructive pulmonary disease) and acute respiratory failure.
A review of the comprehensive care plan dated 5/9/23 revealed, FOCUS: The resident has altered respiratory status/difficulty breathing and COPD. INTERVENTIONS: OXYGEN SETTINGS: Bi-pap at night- FIO2 30 %.
A review of the physician orders dated 6/13/23 revealed, Bi-pap at night- FIO2 30% every evening and night shift for sob (shortness of breath). Bi-pap keep covered when not in use, every day shift.
On 9/20/23 at 11:10 AM, an interview was conducted with LPN (licensed practical nurse) #2. When asked to observe Resident #49's bi-pap mask, LPN #2 stated, the resident must have taken the mask off at the end of night shift and is out for an appointment. LPN #2 stated they usually have a bag attached to the bedside cabinet that the mask can be put in with a date. The bag was not there for the resident to put the mask in. When asked if the mask should be laying on the bed, LPN #2 stated, no, the mask should not be laying on her bed due to infection control issues, it should be in a bag.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
A review of the facility's Resident Care Equipment-Cleaning policy revealed, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard.
No further information was provided prior to exit.
2. Resident #120's urinary catheter (Foley) bag was observed on the floor on 9/19/23 at 1:40 PM and 2:45 PM.
Resident #120 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes,
osteomyelitis, sepsis and BPH (benign prostatic hypertrophy).
A review of the baseline care plan dated 9/14/23 revealed, FOCUS: The resident has Indwelling Catheter:
history of BPH. INTERVENTIONS: The resident has 16 FR/10cc Position catheter bag and tubing below
the level of the bladder and away from entrance room door. Dignity bag to cover drainage bag content.
On 9/20/23 at 8:10 AM, an interview was conducted with RN (registered nurse) #2. When asked what was the proper placement of a Foley bag, RN #2 stated, it should be below the bladder level and is usually hung on the side of the bed. When asked if the Foley bag should be on the floor, RN #2 stated, no, it should never be on the floor. When asked why it should not be on the floor, RN #2 stated, it is against infection control practice.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was 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
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on staff interview and facility document review, it was determined the facility staff failed to maintain a complete antibiotic stewardship program. The facility failed to evidence documentation ...
Read full inspector narrative →
Based on staff interview and facility document review, it was determined the facility staff failed to maintain a complete antibiotic stewardship program. The facility failed to evidence documentation of antibiotic use monitoring for December 2022.
The findings include:
The facility staff could not evidence antibiotic use monitoring for the month of December 2022.
The antibiotic stewardship program was reviewed. The last twelve months were reviewed. There was no evidence of any monitoring for December 2022. A request was made on 9/19/2023 at 4:32 p.m., to ASM (administrative staff member) #1, the administrator, for the December documentation.
On 9/20/2023 at 10:21 a.m. ASM #1 and ASM #2, the director of nursing, stated the facility did not have the documentation for December 2022. ASM #2 stated she attempted to get the records from the previous pharmacy and since she didn't have clearance any longer with that pharmacy, she was unable to access the report. ASM #1 and ASM #2 were made aware of the above concern.
The facility policy, Antibiotic Stewardship documented in part, Purpose: Antibiotics will be prescribed and administered to resident under the guidance of the facility's Antibiotic Stewardship Program. Implementation and Interpretation: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide education and offer the pneumococcal vaccinati...
Read full inspector narrative →
Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide education and offer the pneumococcal vaccination for one of five residents reviewed for immunizations; Resident #108.
The findings include:
For Resident #108 (R108), the facility staff failed to provide education and offer the pneumococcal vaccination.
On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/8/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs it was coded the resident's pneumococcal vaccination was not up to date and that the resident had been offered and declined the vaccination.
The electronic clinical record documented under Immunization tab; it was documented Pneumovax 23 - consent refused.
A request was made on 9/19/2023 at 4:30 p.m. for the documentation of the education provided and the documented declination for the pneumococcal vaccination.
On 9/20/2023 the facility presented a form, Pneumococcal Informed Consent dated 9/19/2023 with the resident's signature. It was documented, I hereby give the facility permission to administer a pneumococcal vaccination.
An interview was conducted with R108 on 9/20/2023 at 8:49 a.m. When asked if he was offered a pneumonia vaccine before yesterday, 9/19/2023, R108 stated he couldn't recall being asked about it before yesterday.
An interview was conducted with LPN (licensed practical nurse) #3 on 9/20/2023 at 9:56 a.m. When asked the process for screening for vaccination status of a new resident, LPN #3 stated, usually on admission she goes to the vaccination data base for Virginia. She stated she transfers the information into the clinical record. When explain R108's record documented consent refused, LPN #3 stated they ask the resident if they want the vaccines. Usually, we put it in the immunization tag. When asked if they provide any education to the resident related to the vaccines, LPN #3 explained prior to current ownership, they had a tab in the immunization tab to document the consent and education. They don't have it any longer. LPN #3 stated she had talked to R108 last evening and he agreed to take the pneumococcal vaccination.
The facility policy, Pneumococcal Vaccine, documented in part, Policy: Residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .Specific Procedures/Guidance: 1. Prior to or upon admission, resident will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.
ASM (administrative staff member) #1, the administrator, was made aware of the above finding on 9/20/2023 at 10:30 a.m.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
Based on observations, resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence bed inspections for one of 40 ...
Read full inspector narrative →
Based on observations, resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence bed inspections for one of 40 resident beds in the survey sample, Resident #52.
The findings include:
For Resident #52, the facility staff failed to perform bed rail inspections for the use of positioning/assist bars.
A review of the comprehensive care plan dated 6/19/23, which revealed, FOCUS: The resident is at risk for falls related to limited mobility. INTERVENTIONS: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
Resident #52 was observed resting in bed on 9/19/23 at 1:20 PM, 9/20/23 at 8:50 AM and 9/21/23 at 8:00 AM with bilateral one quarter rails raised on bed.
A review of the facility's Side Rail Risk and Entrapment form dated 6/19/23 revealed Recommendations: Use both upper 1/4 rails for independent bed mobility. Reason for side rail use: to assist with bed positioning.
An interview was conducted on 9/19/23 at 1:20 PM with Resident #52. When asked if he used the rails, Resident #52 stated, Yes, I use the rails to turn in bed and to position myself.
An interview was conducted on 9/19/23 at 2:54 PM with OSM (other staff member) #6, the maintenance director. When asked about bed inspections, OSM #6 stated, We have no bed inspections. I have been here 4 weeks and am in the process of going through every bed to inspect and make sure they are safe for now and ordering parts that need to be replaced. Unable to locate any bed inspections for risk of entrapment prior to me starting. I called the previous director but he has not returned my calls.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
A review of the facility's Bed Rail Safety Inspection policy, revealed, To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall conduct regular bed safety inspections and will promote the following approaches: Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement or bed position.). Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.).
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
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 ensure an accessible call bell in th...
Read full inspector narrative →
Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure an accessible call bell in the bathroom for one of 40 residents in the survey sample, Resident #76.
The findings include:
For Resident #76 (R76), the facility staff failed to ensure the call light was within reach in the bathroom.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/15/2023, the residents cognition status was not assessed. Section G documented R76 requiring supervision for walking in the room and corridor and extensive assistance of one person for toileting. The resident was assessed as being frequently incontinent.
On 9/19/2023 at 12:34 p.m., an observation was made of R76's bathroom. R76 was observed sitting on the side of their bed with a walker in front of them. The wall beside R76's commode contained a call light panel with no pull cord attached. The call light was observed to not be accessible to the resident from the floor if needed. At that time an interview was conducted with R76. R76 stated that the cord had come out of the wall over a week ago and they had taken the cord to the nurses station and given it to the nurse on duty at the time and asked them to have maintenance repair it. R76 stated that they used the bathroom and was scared that if they fell they would not be able to call anyone because they would not be able to reach the call light. R76 stated that the nursing staff had told them several times that they would have someone come fix the cord on the light but no one had come.
Additional observations of R76's bathroom were made on 9/20/2023 at 8:55 a.m. and 9/20/2023 at 1:45 p.m. The call light in the bathroom remained without a pull cord accessible to the resident from the floor if needed.
On 9/20/2023 at 2:13 p.m., an interview was conducted with CNA (certified nursing assistant) #8. CNA #8 stated that they were not aware of any problems with any resident call lights on the unit. She stated that all residents should have access to the call light and if there were any problems with the call light they put in requisitions to have maintenance come to repair them.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that all residents should have access to the call light when in the bathroom. She stated that it was a safety issue so they could call the staff if they needed assistance.
On 9/20/2023 at 2:51 p.m., an interview was conducted with OSM (other staff member) #6, the director of maintenance. OSM #6 stated that they utilized a computer system which all staff were able to enter work orders into for repairs. He stated that he checked the system at least once a day and added comments for repairs needed or closed out completed repairs. OSM #6 checked his maintenance requests for R76's bathroom call light and stated that it had not been reported to him. He observed the call light in R76's bathroom with no pull cord and stated that there should be a cord in place for the resident to be able to access it if needed.
The facility policy Answering the Call light documented in part, The facility will maintain a functional call light system and will make all reasonable efforts to ensure timely responses to the resident's requests and needs .Explain to the resident that a call system is also located in his/her bathroom . Report all defective call lights to the licensed nurse and the maintenance promptly .
On 9/21/2023 at 1:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a significant change in condition and/or a need to alter treatment i...
Read full inspector narrative →
Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a significant change in condition and/or a need to alter treatment in a timely manner for two of 40 residents in the survey sample, Residents #106 and #96.
The findings include:
1. For Resident #106 (R106), the facility staff failed to notify the physician of a pressure injuries in a timely manner.
A physical therapy evaluation dated 5/19/23 documented R106 presented with unstageable bilateral heel pressure areas (injuries) (1). Further review of R106's clinical record failed to reveal the physician was notified of the pressure injuries until 6/2/23. A physician note dated 6/2/23 documented, SKIN: (Name) indicated that patient has dark area on both heels. Wound care team to follow. Warm and dry. No induration, nodules, or discoloration .
On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated nurses should notify the physician and obtain treatment orders when a resident is admitted with pressure injuries and when a resident develops pressure injuries.
On 9/21/23 at 11:28 a.m., an interview was conducted with OSM (other staff member) #7 (R106's physical therapist). OSM #7 stated he reported R106's pressure injuries to the nursing staff on 5/19/23.
On 9/21/23 at 1:28 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, Pressure Injury Prevention And Management documented, 3. Observations of new pressure ulcer/injury will be: a. Reported to the physician/practitioner for further evaluation and treatment.
Reference:
(1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a
bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear .
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss.
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue) . This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
2. For Resident #96 (R96), the facility staff failed to notify the physician when the medication Nubeqa (1) was not available for administration on multiple dates in August 2023.
A review of R96's clinical record revealed a physician's order dated 8/24/23 for Nubeqa 300 mg (milligrams)- two tablets by mouth two times a day for prostate cancer. A review of R96's August 2023 MAR (medication administration record) revealed the same physician's order for Nubeqa. On 8/26/23 (a.m. and p.m. doses), 8/27/23 (a.m. and p.m. doses), 8/28/23 (p.m. dose), 8/29/23 (p.m. dose), 8/30/23 (p.m. dose) and 8/31/23 (a.m. dose), the the code, 9=Other / See Nurse Notes. Nurses' notes dated 8/26/23 documented, Will administer when med arrive from pharmacy and Medication out of stock, resident made aware, will continue to monitor was documented on the MAR.
Nurses' notes dated 8/27/23 had documented, Will administer when med arrive from pharmacy and Awaiting delivery from pharmacy. A nurse's note dated 8/28/23 had documented, Medication not in stock, reorder on 8/24/23. A nurse's note dated 8/29/23 had documented, Medication reordered as currently unavailable [sic]. A nurse's note dated 8/30/23 had documented, On order from pharmacy. A nurse's note dated 8/31/23 had documented, Will administer when med arrive from pharmacy. Further review of nurses' notes and the August 2023 MAR failed to reveal documentation that Nubeqa was administered to R96 on the above dates, and failed to reveal the physician was notified until 9/1/23.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that if a medication is not available for administration, the nurses are supposed to notify the doctor and see what he recommends. LPN #3 stated this should be done each time a medication is not available, and this should be documented in the clinical record.
On 9/21/23 at 1:28 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 pharmacy policy titled, General Guidelines for Medication Administration documented, If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response.
Reference:
(1) Darolutamide (Nubeqa) is used to treat certain types of prostate cancer .Do not stop taking darolutamide without talking to your doctor. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a619045.html
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #52, the facility staff failed to develop the comprehensive care plan for bed rails.
Resident #52 was admitted t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #52, the facility staff failed to develop the comprehensive care plan for bed rails.
Resident #52 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hemiplegia, hemiparesis, morbid obesity and congestive heart failure.
A review of the comprehensive care plan dated 6/19/23, which revealed, FOCUS: The resident is at risk for falls related to limited mobility. INTERVENTIONS: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
A review of the physician orders revealed no order for bed rails.
Resident #52 was observed resting in bed on 9/19/23 at 1:20 PM, 9/20/23 at 8:50 AM and 9/21/23 at 8:00 AM with bilateral one quarter rails raised on bed.
A review of the facility's Side Rail Risk and Entrapment form dated 6/19/23 revealed Recommendations: Use both upper 1/4 rails for independent bed mobility. Reason for side rail use: to assist with bed positioning.
An interview was conducted on 9/19/23 at 1:20 PM with Resident #52. When asked if he used the rails, Resident #52 stated, Yes, I use the rails to turn in bed and to position myself.
An interview was conducted on 9/21/23 at 9:15 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, the purpose of the care plan is the action of the care while they are here and that bed rails should be on the care plan due to the resident's need to use them for turning and positioning.
On 9/21/23 at 1:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant was made aware of the findings.
No further information was presented prior to exit.
5. For Resident #62 (R62), the facility staff failed to implement the comprehensive care plan to use a cigarette extender and smoking apron while smoking.
On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 6/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. Section J documented no current tobacco use.
On 9/19/2023 at 2:30 p.m., an observation was made of R62 in the facility courtyard smoking. R62 was observed smoking two cigarettes during the supervised smoke break without using a cigarette extender or smoking apron.
On 9/19/2023 at 3:56 p.m., an interview was conducted with R62. R62 stated that they had smoked for years and had been smoking at the facility since admission. R62 stated that the facility stored their cigarettes and lighter in a box that they took at during the smoking times. R62 stated that they had a cigarette extender that they kept in their room and they took it outside sometimes. R62 stated that the facility used to require them to use smoking aprons at one time but they were not required anymore.
On 9/19/2023 at 4:30 p.m., an additional observation was conducted of R62 in the facility courtyard smoking. R62 was observed smoking during the supervised smoke break without the use of a cigarette extender or smoking apron.
The comprehensive care plan for R62 documented in part, History of smoking and current smoker
Date Initiated: 12/06/2019. Revision on: 08/09/2023. Under Interventions it documented in part, Assist/ensure cigarette extender is used during designated smoke times. Date Initiated: 03/29/2022. Revision on: 01/11/2023 . Provide with a smoking apron and assist to put on. Date Initiated: 02/19/2020. Revision on: 01/11/2023 .
The Smoking-Resident Safety Evaluation for R62 dated 2/9/2023 documented in part, .Tobacco Utilization: 1. Does the resident use tobacco products? Yes. Does the facility allow smoking? Yes. Tobacco products utilized: Cigarettes/Cigars . Resident adaptive equipment needs: a. Smoking apron, b. Cigarette holder, c. Supervision .
On 9/19/2023 at 3:45 p.m., an interview was conducted with CNA (certified nursing assistant) #11. CNA #11 stated that residents met in the room by the courtyard prior to going out to smoke at the scheduled times and were supposed to put on smoking aprons prior to going out if they required them. She stated that she knew which residents required smoking aprons because she worked with them so often. She stated that she knew that R62 had a cigarette extender that they kept in their room to bring with them.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to keep track of the residents care in the facility and contained all aspects of their care. She stated that the care plan should be implemented to make sure the resident was getting the proper care and treatment.
On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN #3. LPN #3 stated that the purpose of the care plan was to provide an action of care and documented why the resident was there. She stated that the care plan was implemented by the nurses having access to the care plan if they needed it and having MDS available if they had any questions about the care plan.
On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
6. For Resident #76 (R76), the facility staff failed to implement the comprehensive care plan to ensure the call light was within reach.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/15/2023, the residents cognition status was not assessed. Section G documented R76 requiring supervision for walking in the room and corridor and extensive assistance of one person for toileting. The resident was assessed as being frequently incontinent.
On 9/19/2023 at 12:34 p.m., an observation was made of R76's bathroom. R76 was observed sitting on the side of their bed with a walker in front of them. The wall beside R76's commode contained a call light panel with no pull cord attached. The call light was observed to not be accessible to the resident from the floor if needed. At that time an interview was conducted with R76. R76 stated that the cord had come out of the wall over a week ago and they had taken the cord up to the nurses station and given it to the nurse on duty at the time and asked them to have maintenance repair it. R76 stated that they used the bathroom and was scared that if they fell they would not be able to call anyone because they would not be able to reach the call light. R76 stated that the nursing staff had told them several times that they would have someone come fix the cord on the light but no one had come.
Additional observations of R76's bathroom were made on 9/20/2023 at 8:55 a.m. and 9/20/2023 at 1:45 p.m. The call light in the bathroom remained without a pull cord accessible to the resident from the floor if needed.
The comprehensive care plan for R76 documented in part, (Name of R76) is at risk for falls r/t (related to) limited mobility. Date Initiated: 05/30/2023. Revision on: 06/07/2023. Under Interventions it documented, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 05/30/2023.
On 9/20/2023 at 2:13 p.m., an interview was conducted with CNA (certified nursing assistant) #8. CNA #8 stated that they were not aware of any problems with any resident call lights on the unit. She stated that all residents should have access to the call light and if there were any problems with the call light they put in requisitions to have maintenance come to repair them.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to keep track of the residents care in the facility and contained all aspects of their care. She stated that the care plan should be implemented to make sure the resident was getting the proper care and treatment.
On 9/20/2023 at 2:51 p.m., an interview was conducted with OSM (other staff member) #6, the director of maintenance. OSM #6 stated that they utilized a computer system which all staff were able to enter work orders into for repairs. He stated that he checked the system at least once a day and added comments for repairs needed or closed out completed repairs. OSM #6 checked his maintenance requests for R76's bathroom call light and stated that it had not been reported to him. He observed the call light in R76's bathroom with no pull cord and stated that there should be a cord in place for the resident to be able to access it if needed.
On 9/21/2023 at 1:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
7. For Resident #11 (R11), the facility staff failed to develop the comprehensive care plan for hospice services.
On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/5/2023, the resident was coded as receiving hospice services while a resident at the facility.
The comprehensive care plan for R11 failed to evidence hospice services.
The physician orders for R11 documented in part, Admit to (Name and phone number of hospice). Order Date: 7/5/2023.
The progress notes documented in part, 7/11/2023 11:31 (11:31 a.m.) Note Text : readmission note for (age and sex of R11) LTC (long term care) under hospice services recently hospitalized r/t (related to) seizures .
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to keep track of the residents care in the facility and contained all aspects of their care. She stated that MDS staff and nursing both developed the care plans. She stated that she was not sure if hospice was on the care plan or not because hospice residents at the facility were more functional than the ones they normally worked with.
On 9/20/2023 at 2:34 p.m., an interview was conducted with RN (registered nurse) #5, MDS coordinator. RN #5 stated that MDS was responsible for the comprehensive care plan. She stated that the MDS staff care planned anything that triggered from the MDS assessment and the nursing staff, dietician, social worker and activities added additional things. She stated that the care plan purpose was to guide the residents care and hospice residents should have a care plan addressing hospice services. She reviewed R11's care plan and stated that she did not see anything regarding hospice.
On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
8. For Resident #16 (R16), the facility staff failed to implement the comprehensive care plan to monitor weights.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/7/2023, the resident was coded as no or unknown for weight loss in the past 6 months. The resident was assessed as receiving a therapeutic diet.
The comprehensive care plan for R16 documented in part, (Name of R16) is at risk for hydration/nutrition imbalance in setting of therapeutic diet, h/o (history of) obese BMI (body mass index), and multiple chronic disease states, hx (history) of lymphedema, h/o significant wt (weight) loss. Date Initiated: 11/06/2017. Revision on: 03/08/2023. Under Interventions it documented in part, . Review weights and notify physician and responsible party of significant weight change. Date Initiated: 11/06/2017.
The physician orders for R16 documented in part, No labs, no vitals. Continue monthly weights. Order Date: 3/3/2023.
The weight summary for R16 documented a weight of 179.0 lbs (pounds) on 3/6/2023 and a weight of 179.4 lbs on 9/6/2023. The weight summary failed to evidence weights obtained for 4/2023, 5/2023, 6/2023, 7/2023 or 8/2023.
Review of the clinical record failed to evidence refusals of weights between 4/1/2023-8/31/2023.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to keep track of the residents care in the facility and contained all aspects of their care. She stated that the care plan should be implemented. She stated that residents were weighed at least monthly unless ordered more frequently and if they refused weights it was documented in the progress notes.
On 9/20/2023 at 2:13 p.m., an interview was conducted with CNA (certified nursing assistant) #8. CNA #8 stated that all residents were weighed at least monthly and more often if the nurses told them it was needed. She stated that if the resident refused they waited and attempted later that day and if they still refused they let the nurse know.
On 9/21/2023 at 1:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for eight of 40 residents in the survey sample, Residents #48, #108, #52, #219, #62, #76, #11, and #16.
The findings include:
1. For Resident #48 (R48), the facility staff failed to develop a comprehensive care plan for the resident's laryngectomy tube (1).
R48 was admitted to the facility on [DATE] with a diagnosis of the presence of an artificial larynx (a laryngectomy tube). A review of R48's comprehensive care plan initiated on 6/6/23 failed to reveal documentation regarding the resident's laryngectomy tube.
On 9/20/23 at 8:34 a.m., R48 was observed sitting on the bed and the resident was observed to have a laryngectomy tube. At this time, an interview was conducted with R48. The resident was unable to verbally communicate but communicated via non-verbal gestures and by writing on a communication board. R48 was asked if the nurses clean and provide care for his laryngectomy tube. The resident nodded his head side to side indicating, No and pointed to himself. When asked if he provides the care, R48 nodded his head up and down indicating, Yes. When asked if the nurses check to make sure he is cleaning and caring for his laryngectomy tube, R48 nodded his head side to side, indicating, No.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated, The purpose of the care plan is the action of the care while they [the residents] are here. LPN #3 stated residents' care plans should include documentation regarding a laryngectomy tube and usually the care plan documents what needs to be done, suction prn (as needed), make sure care is provided, notify the physician of any secretions or signs of infection, and monitor the resident's temperature and oxygen level.
On 9/21/23 at 1:28 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, Care Planning - Comprehensive Person-Centered documented,
13. The comprehensive care plan will:
a. Incorporate identified problem areas;
b. Incorporate risk factors associated with identified problems;
c. Build on the resident's strengths;
d. Be culturally competent and trauma-informed as applicable
e. Reflect treatment goals, timetables and objectives in measurable outcomes;
f. Identify the professional services that are responsible for each element of care;
g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels;
h. Promote resident safety;
i. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and
j. Reflect currently recognized standards of practice for problem areas and conditions.
Reference:
(1) A laryngectomy tube is used after the removal of the larynx (the voice box in the throat). This information was obtained from the website: https://medlineplus.gov/ency/article/007398.htm
2. For Resident #108 (R108), the facility staff failed to implement the resident's comprehensive care for pressure injury assessment and documentation.
R108 was admitted to the facility on [DATE] with a diagnosis of a stage four pressure injury on the sacral region (1). R108's comprehensive care plan dated 6/4/23 documented, I have actual impairment to skin integrity r/t (related to) right ischium (inaccurate documentation of location). Assess/Monitor/Document wound: size, depth, margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis per facility protocols .
A review of R108's clinical record failed to reveal thorough assessments of the pressure injury and progress in wound healing in August 2023 and September 2023. The only documentation regarding the resident's skin was a weekly skin observation dated 8/7/23 that documented no open areas, a weekly skin observation dated 8/15/23 that documented an open area on the left buttock, a weekly skin observation dated 8/21/23 regarding another skin concern but did not contain any documentation regarding the pressure injury, a weekly skin observation dated 8/29/23 that documented no open areas and a weekly skin observation dated 9/6/23 that documented an open area on the left buttock.
On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse).
On 9/21/23 at 9:16 a.m., another interview was conducted with LPN #3. LPN #3 stated, The purpose of the care plan is the action of the care while they [the residents] are here. In regard to care plan implementation, LPN #3 stated the nurses have access to the care plans and the MDS (minimum data set) staff is available if nurses have questions about the care plan.
On 9/21/23 at 1:28 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) Stage 4 Pressure Injury: Full-thickness skin and tissue loss.
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
4. For Resident #219, the facility staff failed to implement the comprehensive care plan during medication administration.
Resident #219 was admitted on [DATE] and had the diagnoses of high blood pressure (HTN), atrial fibrillation (Afib), lymphedema and non-pressure chronic ulcer of the skin.
A review of the comprehensive care plan dated 9/19/23 revealed the following:
(Resident #219) is at risk for potential nutritional problems . Interventions included one dated 9/19/23 for Meds and Labs as ordered.
I have actual impairment to skin integrity Interventions included one dated 9/19/23 for Administer medications, supplements and treatments as ordered
(Resident #219) has hypertension (HTN). Interventions included one dated 9/19/23 for Give anti hypertensive medications as ordered
A review of the physician's orders revealed the following:
(1) Aspirin an 81 mg (milligrams) tablet once daily. Order dated 9/8/23.
(2) Valsartan an 80 mg tablet once daily. Order dated 9/8/23.
(3) Vitamin D3 a 25 mcg (micrograms) tablet. Give two tablets once daily. Order dated 9/9/23.
(4) Zinc a 220 mg tablet once daily for wound healing. Order dated 9/13/23.
On 9/20/23 at 9:05 AM, the medication administration observation was conducted with LPN #10 (Licensed Practical Nurse), for Resident #219. Upon review of the physician's orders and the Medication Administration Record (MAR) for September 2023 revealed that the Aspirin, Valsartan, Vitamin D3 and Zinc were ordered but were not prepared and administered on observation.
On 9/20/23 at 1:10 PM, an interview was conducted with LPN #10. She stated that she thought she pulled and administered the above medications. She stated that she did not know how she missed them.
On 9/20/23 at 1:50 PM, a second follow up interview was conducted with LPN #10. When asked if the care plan documented to administer medications as ordered, and the medications were missed, was the care plan being followed, she stated that it was not. When asked what was the purpose of the care plan, she stated so that everyone knows how to care for the resident.
The facility policy Care Planning - Comprehensive Person-Centered was reviewed. This policy documented, . A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process
On 9/20/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #4, the Regional Nurse Consultant, were made aware of the findings. No further information was provided by the end of the survey.
References:
(1) Aspirin - Is used to prevent heart attacks, strokes, and reduce the risk of death from a heart attack or stroke.
Information obtained from https://medlineplus.gov/druginfo/meds/a682878.html
(2) Valsartan - Is used alone or in combination with other medications to treat high blood pressure.
Information obtained from https://medlineplus.gov/druginfo/meds/a697015.html
(3) Vitamin D3 - Is used as a dietary supplement when the amount of vitamin D in the diet is not enough .is also used along with calcium to prevent and treat bone diseases .
Information obtained from https://medlineplus.gov/druginfo/meds/a620058.html
(4) Zinc - Is an essential trace element commonly found in red meat, poultry, and fish. It is necessary in small amounts for human health, growth, and sense of taste. Zinc is found throughout the body. The body doesn't store excess zinc, so it must be obtained from the diet. It's needed for immune function, wound healing, blood clotting, thyroid function, and much more. It also plays a key role in maintaining vision and might have effects against viruses.
Information obtained from https://medlineplus.gov/druginfo/natural/982.html)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor weights for two of 40 residents in the su...
Read full inspector narrative →
Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor weights for two of 40 residents in the survey sample, Residents #53 and #16.
The findings include:
1. For Resident #53 (R53), the facility staff failed to monitor weights between 6/9/2023-9/20/2023.
On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/5/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The resident was coded as no or unknown for weight loss in the past 6 months.
The nutritional at risk assessment for R53 dated 8/3/2023 documented in part, . Annual assessment for (age and sex) LTC (long term care) female w/hx (with history) of UTI (urinary tract infection), PNA (pneumonia), HTN (hypertension), anemia, GERD, hypothyroidism, paraplegia, depression, chronic pain, BPD (bipolar disorder), DVT (deep vein thrombosis). Ht (height) 66, last wt (weight) obtained 6/2023 no significant weight change at that time; 8/2023 weight pending . No nutrition-related recommendations at this time, continue to monitor PO (by mouth) and weight change status .
The comprehensive care plan for R53 documented in part, (R53) has the potential for alteration in nutritional status r/t (related to) multiple medical dx (diagnoses), paraplegia, MDD (major depressive disorder), bipolar disorder, GERD (gastroesophageal reflux disorder), BMI (body mass index) is obese, will eat meals brought in by family instead of facility meals at times. Date Initiated: 09/23/2021. Revision on: 06/20/2023.
The weight summary for R53 failed to evidence a weight obtained after 6/9/2023.
The clinical record for R53 failed to evidence documentation of refusal of weights between 6/10/2023-9/20/2023.
On 9/20/2023 at 2:13 p.m., an interview was conducted with CNA (certified nursing assistant) #8. CNA #8 stated that all residents were weighed at least monthly and more often if the nurses told them it was needed. She stated that if the resident refused they waited and attempted later that day and if they still refused they let the nurse know.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that residents weights were obtained on admission and then monthly. She stated that if a resident refused to be weighed they documented it in the nurses notes.
On 9/21/2023 at 11:14 a.m., an interview was conducted with OSM (other staff member) #5, registered dietician. OSM #5 stated that they monitored residents for changes in weight status, weight loss and/or gain. She stated that unless a resident triggered for weight loss or gain the weight was monitored monthly. She stated that if a resident refused to be weighed they should be notified but they were not sure of the policy and/or procedure at the facility.
The facility policy Weight Assessment and Intervention documented in part, The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . 1. The nursing staff/designee will measure resident weights on admission as ordered by the physician/practitioner. a. If no weight concerns are noted weights will be measured monthly . 2. Weights will be recorded in in the resident's medical record .
On 9/21/2023 at 1:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
2. For Resident #16 (R16), the facility staff failed to monitor weights in 4/2023, 5/2023, 6/2023, 7/2023 or 8/2023.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/7/2023, the resident was coded as no or unknown for weight loss in the past 6 months. The resident was assessed as receiving a therapeutic diet.
The physician orders for R16 documented in part, No labs, no vitals. Continue monthly weights. Order Date: 3/3/2023.
The weight summary for R16 documented a weight of 179.0 lbs (pounds) on 3/6/2023 and a weight of 179.4 lbs on 9/6/2023. The weight summary failed to evidence weights obtained for 4/2023, 5/2023, 6/2023, 7/2023 or 8/2023.
The comprehensive care plan for R16 documented in part, (Name of R16) is at risk for hydration/nutrition imbalance in setting of therapeutic diet, h/o (history of) obese BMI (body mass index), and multiple chronic disease states, hx (history) of lymphedema, h/o significant wt (weight) loss. Date Initiated: 11/06/2017. Revision on: 03/08/2023.
Review of the clinical record failed for R16 to evidence refusals of weights between 4/1/2023-8/31/2023.
On 9/20/2023 at 2:13 p.m., an interview was conducted with CNA (certified nursing assistant) #8. CNA #8 stated that all residents were weighed at least monthly and more often if the nurses told them it was needed. She stated that if the resident refused they waited and attempted later that day and if they still refused they let the nurse know.
On 9/20/2023 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that residents weights were obtained on admission and then monthly. She stated that if a resident refused to be weighed they documented it in the nurses notes.
On 9/21/2023 at 11:14 a.m., an interview was conducted with OSM (other staff member) #5, registered dietician. OSM #5 stated that they monitored residents for changes in weight status, weight loss and/or gain. She stated that unless a resident triggered for weight loss or gain the weight was monitored monthly. She stated that if a resident refused to be weighed they should be notified but they were not sure of the policy and/or procedure at the facility.
On 9/21/2023 at 1:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided 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** Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility sta...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for two of 40 residents in the survey sample, Residents #270 and #48.
The findings include:
1. For Resident #270 (R270), the facility staff failed to obtain physician's orders for the care of the resident's laryngectomy tube (1), failed to assess R270 for self-care of the laryngectomy tube, and failed to provide oversight to ensure the resident's care of the laryngectomy tube.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/17/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.
A review of R270's clinical record failed to reveal physician's orders for the care of the resident's laryngectomy tube. R270's comprehensive care plan revised on 9/1/23 failed to reveal documentation regarding the resident's laryngectomy tube. Further review of R270's clinical record from the resident's readmission on [DATE], failed to reveal the resident was assessed for self-care of the laryngectomy tube, and failed to reveal oversight was provided to ensure the resident was performing care of the laryngectomy tube (except for 9/8/23 and 9/9/23).
On 9/20/23 at 8:34 a.m., R270 was observed sitting on the bed and the resident was observed to have a laryngectomy tube. At this time, an interview was conducted with R270. The resident was unable to verbally communicate but communicated via non-verbal gestures and by writing on a communication board. R270 was asked if the nurses clean and provide care for his laryngectomy tube. The resident nodded his head side to side indicating, No and pointed to himself. When asked if he provides the care, R270 nodded his head up and down indicating, Yes. When asked if the nurses check to make sure he is cleaning and caring for his laryngectomy tube, R270 nodded his head side to side, indicating, No. R270 pointed to his supply of neck bands and wrote on his communication board that he needed more neck bands and a brush to clean the tube.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated an evaluation should be completed to make sure a resident is safe and able to perform his own trach/laryngectomy tube care. LPN #3 stated the nurses can provide assisted to R270, but the resident really takes care of his laryngectomy tube. LPN #3 stated the resident will let staff know when he needs supplies and the nurses should offer assistance, document that assistance was offered, document that supplies were provided, and document if R270 accepts or declines assistance. LPN #3 stated this should occur at least once a day or per whatever the physician's order says. LPN #3 stated that if there is no physician's order then the nurses need to call the doctor and get an order.
On 9/21/23 at 1:28 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, Self-Administration of Medications and Treatments documented, POLICY: Residents have the right to self-administer medications / treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.
SPECIFIC PROCEDURES / GUIDANCE
1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments is clinically appropriate for the resident.
2. The staff and practitioner may ask residents who are identified as being able to self-administer medications/treatments whether they wish to do so.
3. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, which may include (but not limited to) the resident's:
a. Ability to read and understand medication labels / treatment instructions;
b. Comprehension of the purpose and proper administration for his or her medications/treatments.
c. Ability to remove medications and/or treatment supplies from a container
d. Ability to recognize risks and major adverse consequences of his or her medications/treatments.
4. If the team determines that a resident cannot safely self-administer medications/treatments, the nursing staff will administer the resident's medications.
5. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications/treatments.
6. For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting those medications were taken and/or that treatments were administered .
12. Nursing staff will review the self-administered medication/treatment record on each nursing shift, and they will transfer pertinent information to the medication/treatment administration record (MAR/TAR) appropriately noting that the doses were self-administered .
Reference:
(1) A laryngectomy tube is used after the removal of the larynx (the voice box in the throat). This information was obtained from the website: https://medlineplus.gov/ency/article/007398.htm
2. For Resident #48 (R48), the facility staff failed to obtain a physician's order for the use of an incentive spirometer and failed to store the incentive spirometer in a sanitary manner.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/28/23, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions.
A review of R48's clinical record failed to reveal a physician's order for an incentive spirometer. R48's care plan dated 9/19/23 failed to document information regarding an incentive spirometer.
On 9/19/23 at 11:34 a.m., R48 was observed sitting in a wheelchair in the bedroom. An incentive spirometer was observed sitting on the resident's overbed table. The incentive spirometer was uncovered, and the mouthpiece was exposed to air.
On 9/21/23 at 8:19 a.m., R48 was observed sitting in a wheelchair in the bedroom. The incentive spirometer was observed sitting on the bed, uncovered, with the mouthpiece exposed to air. At this time, an interview was conducted with R48. The resident stated he uses the incentive spirometer once or twice a day and staff had not provided a bag or cover for the device.
On 9/21/23 at 9:16 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated residents should have a physician's order for the use of an incentive spirometer because everything has to have a doctor's order. LPN #3 stated an incentive spirometer should be stored in a little baggie for infection control purposes.
On 9/21/23 at 1:28 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, resident interview, clinical record review and facility document review, it was determine...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for two of 40 residents in the survey sample, Resident #119 and Resident #83.
The findings include:
1. For Resident #119, the facility failed to provide a bagged lunch to take to the dialysis appointments for four of four days and to failed to communicate with the dialysis facility for three of four days.
Resident #119 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), dialysis and acute pancreatitis.
The most recent MDS (minimum data set) assessment, an uncompleted Medicare 5-day assessment, with an ARD (assessment reference date) of 9/16/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-was incomplete. Section O- Special Procedures/Treatments was incomplete.
A review of the physician's order dated 9/12/23 revealed, Dialysis every T-TH-SA.
A review of Resident #119's dialysis communication book revealed a communication sheet for 9/12/23, however there were no communication sheets for 9/14/23, 9/16/23 and 9/19/23.
An interview was conducted on 9/20/23 at 8:40 AM with Resident #119 and when asked what items he took with him to dialysis, Resident #119 stated, there was nothing. When asked if he takes a bagged meal or a communication binder, Resident #119 stated, No, there is no bagged lunch and I do not have binder.
An interview was conducted on 9/20/23 at 8:00 AM with RN #2. When asked the purpose of the dialysis communication form, RN #2 stated, the purpose is to share and receive information with the dialysis center, including vital signs, medications any lab results. When asked to review Resident #119's dialysis communication book, RN #2 stated, there is a form for 9/12/23, but he should have had one for 9/14/23, 9/16/23 and 9/19/23. He is missing three forms. When asked if Resident #119 took a bagged lunch with him, RN #2 stated, That is what I am used to at other places, but there is no bagged lunch for him here. He leaves early in the morning.
An interview was conducted on 9/20/23 at 11:20 AM with OSM (other staff member) #1, the dietary director. When asked if residents are provided a bagged lunch to take to dialysis, OSM #1 stated yes, they are. When asked to describe the process of dietary being notified of a resident needing the bagged lunch, OSM #1 stated, There is usually a renal diet and then nursing lets us know the dialysis schedule and time. For instance, if the resident leaves early in the morning, we make sure the bagged lunch is sent on the Resident's supper tray so it can be put in the refrigerator. If they leave mid-morning, then we send the bagged lunch on the breakfast tray. We do not have this resident on our list as a dialysis resident. When asked to review if Resident #119 is being sent a bagged lunch, OSM #1 stated, no he is not and they have not been notified that he is a dialysis resident and the days and times of dialysis.
On 9/20/23 at 3:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant, were made aware of the findings.
A review of the facility's End Stage Renal Disease-Care of the Patient policy, revealed, Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to:
a. the development of a comprehensive and integrated care plan
b. the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination, and collaboration.
c. timely medication administration
d. advance directives and code status
e. nutritional and fluid management
f. provision and documentation of appropriate access care
g. hemodialysis treatment days and times
No further information was provided prior to exit.
2. For Resident #83 (R83), the facility staff failed to ensure adequate communication and collaboration for care with the resident's hemodialysis center.
A review of R83's clinical record revealed a physician's order dated 6/5/23 for dialysis every Monday, Wednesday, and Friday at 11:45 a.m.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/9/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.
Further review of R83's clinical record failed to reveal communication and collaboration with the hemodialysis center except for a dietary note dated 6/28/23 that documented R83 was to be placed on a fluid restriction, and nurses' notes dated 7/17/23 and 9/11/23 that documented the dialysis center was called to inform staff that R83 refused to go to dialysis those days.
On 9/19/23 at 3:58 p.m., observation of the nurse's station failed to reveal a dialysis communication folder/book for R83. An employee stated the book was probably in R83's room. At that time, an observation of R83's room was conducted. No dialysis communication folder/book was observed and R83 stated she had never been provided a dialysis communication book.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that usually a resident who receives dialysis has a folder with his or her name on it and the nurses are responsible for sending a communication sheet to the dialysis facility each time the resident goes to dialysis. LPN #3 stated the dialysis communication sheet contains information such as the resident's vital signs, documentation about anything that has changed since the last treatment, any recent labs, any changes in the resident's diet, and documentation about the resident's dialysis access.
On 9/21/23 at 1:28 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
CONCERN
(E)
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 40 residents in the survey sample, Resident #96.
The fi...
Read full inspector narrative →
Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 40 residents in the survey sample, Resident #96.
The findings include:
For Resident #96 (R96), the facility staff failed to ensure the medication Nubeqa (1) was available for administration on multiple dates in August 2023.
A review of R96's clinical record revealed a physician's order dated 8/24/23 for Nubeqa 300 mg (milligrams)- two tablets by mouth two times a day for prostate cancer. A review of R96's August 2023 MAR (medication administration record) revealed the same physician's order for Nubeqa. On 8/26/23 (a.m. and p.m. doses), 8/27/23 (a.m. and p.m. doses), 8/28/23 (p.m. dose), 8/29/23 (p.m. dose), 8/30/23 (p.m. dose) and 8/31/23 (a.m. dose), the MAR documented the code, 9=Other / See Nurse Notes Nurses' notes dated 8/26/23 documented, Will administer when med arrive from pharmacy and Medication out of stock, resident made aware, will continue to monitor.
Nurses' notes dated 8/27/23 documented, Will administer when med arrive from pharmacy and Awaiting delivery from pharmacy. A nurse's note dated 8/28/23 documented, Medication not in stock, reorder on 8/24/23. A nurse's note dated 8/29/23 documented, Medication reordered as currently unavailable [sic]. A nurse's note dated 8/30/23 documented, On order from pharmacy. A nurse's note dated 8/31/23 documented, Will administer when med arrive from pharmacy. A nurse's note dated 9/1/23 documented, Writer called pharmacy in regards to Nubeqa tablet. Pharmacy informed writer medication comes from a special pharmacy. MD (Medical Doctor) made aware with new orders noted: Okay to receive medication from resident family. Writer call [sic] resident RP (Responsible Party) who will bring medication to nursing staff 9/2/23.
A review of the facility backup medication supply list revealed Nubeqa was not available in the supply.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that if a medication is not available for administration, the nurses are supposed to notify the doctor and see what he recommends, call the pharmacy to let them know the medication is not at the facility, see how long it will be before the medication arrives, then notify the resident's family and make them aware the medication is not available. LPN #3 stated this should be done each time a medication is not available, and this should be documented in the clinical record.
On 9/21/23 at 1:28 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 pharmacy policy title, General Guidelines for Medication Administration documented, If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit.
Reference:
(1) Darolutamide (Nubeqa) is used to treat certain types of prostate cancer .Do not stop taking darolutamide without talking to your doctor. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a619045.html
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 40 residen...
Read full inspector narrative →
Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 40 residents in the survey sample, Resident #83.
The findings include:
For Resident #83 (R83), the facility staff failed to ensure the physician or nurse practitioner evaluated the resident for continued use of the as needed anti-anxiety medication diazepam (1).
A review of R83's clinical record revealed a physician's order dated 8/4/23 for diazepam 5 mg (milligrams)- one tablet by mouth every eight hours as needed for 180 days for anxiety. A review of R83's August 2023 and September 2023 MARs (medication administration records) revealed the resident was administered as needed diazepam 28 times in August 2023 and 24 times in September 2023. Further review of R83's clinical record failed to reveal the physician or nurse practitioner documented a rationale for extended use and failed to reveal the physician or nurse practitioner evaluated the resident for continued use of the medication after the medication had been administered for 14 days.
On 9/21/23 at approximately 12:20 p.m., a call was placed to R83's nurse practitioner. She was not available for interview.
On 9/21/23 at 1:26 p.m., an interview was conducted with ASM (administrative staff member) #1 (the director of nursing). ASM #1 stated the standard prescription for as needed anti-anxiety medications is for 14 days then the doctor decides if he or she wants to continue the medication or not.
On 9/21/23 at 1:28 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern.
The facility policy titled, Antipsychotic Medication Use documented, 14. The need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order.
Reference:
(1) Diazepam is used to treat anxiety. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682047.html
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free of a significant medication error for one of 40 residents in the ...
Read full inspector narrative →
Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free of a significant medication error for one of 40 residents in the survey sample, Resident #96.
The findings include:
For Resident #96 (R96), the facility staff failed to administer the medication Nubeqa (1), used to treat prostate cancer, on multiple dates in August 2023.
A review of R96's clinical record revealed a physician's order dated 8/24/23 for Nubeqa 300 mg (milligrams)- two tablets by mouth two times a day for prostate cancer. A review of R96's August 2023 MAR (medication administration record) revealed the same physician's order for Nubeqa. On 8/26/23 (a.m. and p.m. doses), 8/27/23 (a.m. and p.m. doses), 8/28/23 (p.m. dose), 8/29/23 (p.m. dose), 8/30/23 (p.m. dose) and 8/31/23 (a.m. dose), the MAR documented the code, 9=Other / See Nurse Notes Nurses' notes dated 8/26/23 documented, Will administer when med arrive from pharmacy and Medication out of stock, resident made aware, will continue to monitor. Nurses' notes dated 8/27/23 documented, Will administer when med arrive from pharmacy and Awaiting delivery from pharmacy. A nurse's note dated 8/28/23 documented, Medication not in stock, reorder on 8/24/23. A nurse's note dated 8/29/23 documented, Medication reordered as currently unavailable [sic]. A nurse's note dated 8/30/23 documented, On order from pharmacy. A nurse's note dated 8/31/23 documented, Will administer when med arrive from pharmacy. A nurse's note dated 9/1/23 documented, Writer called pharmacy in regards to Nubeqa tablet. Pharmacy informed writer medication comes from a special pharmacy. MD (Medical Doctor) made aware with new orders noted: Okay to receive medication from resident family. Writer call [sic] resident RP (Responsible Party) who will bring medication to nursing staff 9/2/23.
On 9/21/23 at approximately 12:20 p.m., a call was placed to R83's nurse practitioner. She was not available for interview.
On 9/21/23 at 12:58 p.m., an interview was conducted with OSM (other staff member) #8 (the quality assurance pharmacist). OSM #8 stated that based on the manufacturer's package information, Nubeqa is usually used for prostate cancer. In regard to the importance of a resident receiving Nubeqa as prescribed, OSM #8 stated that this was patient specific and depended on what other medications the resident was receiving but, Generally chemotherapy is not something you want to miss as a general rule.
On 9/21/23 at 1:28 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, Adverse Consequences and Medication Errors documented, 5. Examples of medications errors include: a. omission-a drug is ordered but not administered .
Reference:
(1) According to the Nubeqa manufacturer's website, Nubeqa is used to treat prostate cancer. The website further documented, TAKE NUBEQA EXACTLY AS YOUR DOCTOR TELLS YOU.
https://www.nubeqa-us.com/what-is-nubeqa#taking-nubeqa
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ...
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, the facility staff failed to maintain an accurate clinical record for one of 40 residents in the survey sample, Resident #108.
The findings include:
For Resident #108 (R108), the facility staff failed to accurately document the location of the resident's pressure injury on multiple weekly wound evaluations and the resident's care plan. R108 presented with a pressure injury on the sacrum (1)/buttock but the wound evaluations and care plan documented the pressure injury was on the right ischial/ischium (2).
R108 was admitted to the facility on [DATE] with a diagnosis of a stage four pressure injury (3) on the sacral region.
A weekly wound evaluation dated 6/2/23 documented R108's pressure injury was located on the right ischium. R108's comprehensive care plan dated 6/4/23 documented, I have actual impairment to skin integrity r/t (related to) right ischium . Weekly wound evaluations dated 6/9/23, 6/16/23, 6/23/23, 6/30/23, and 7/7/23 documented the pressure injury was located on the right ischial. A physician's order dated 6/28/23 documented to cleanse the wound to the right buttock with normal saline, apply normal saline soaked gauze to the open area, and cover with a dry adhesive dressing every shift for wound care. A physician's note dated 9/11/23 documented R108 was admitted with a sacral wound.
On 9/20/23 at 1:10 p.m., an interview was conducted with R108. R108 stated he has had a wound on his buttock for over three years.
On 9/21/23 at 9:16 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who documented the weekly wound evaluations). LPN #3 stated R108's pressure injury was located on his buttock.
On 9/21/23 at 1:28 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, Pressure Injury Prevention and Management documented, 2. Documentation of the evaluations/assessment of the pressure ulcer/injury will [sic] maintained in the resident's medical record. Documentation may include: a. Location of ulcer/injury.
References:
(1) The sacrum is a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/19464.htm
(2) The ischium is the lower and back part of the hip bone. This information was obtained from the website: https://medlineplus.gov/appendixa.html
(3) Stage 4 Pressure Injury: Full-thickness skin and tissue loss.
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on staff interview and facility document review, it was determined the facility staff failed to ensure there was an RN (registered nurse) on duty for eight consecutive hours on 9/16/20223.
The ...
Read full inspector narrative →
Based on staff interview and facility document review, it was determined the facility staff failed to ensure there was an RN (registered nurse) on duty for eight consecutive hours on 9/16/20223.
The findings include:
A review of the last 30 days as-worked schedule was conducted. There was no evidence that an RN was on duty for eight consecutive hours on 9/16/23.
The Nursing Staffing Data for 9/16/2023 had blanks in the spaces for the number of RNs for each shift on 9/16/2023.
An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/20/2023 at 10:25 a.m. When asked the process for ensuring an RN is on duty for eight hours each day, ASM #2 stated the facility usually has RNs on duty as they have both full time and part time RNs. ASM #2 explained that on that day, they had two agency RNs scheduled and they canceled their shifts around 6:00 a.m. She stated she couldn't get coverage. When asked should there be an RN on duty for at least eight consecutive hours each day, ASM #2 stated, yes.
A request was made for the policy regarding RN coverage.
On 9/20/23 at 11:21 a.m., ASM #1, the administrator, stated that they did not have a policy, they just follow the regulations.
ASM #1 and ASM #2 were made aware of the above concerns on 9/20/2023 at 10:25 a.m.
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 the facility staff failed to post the nurse staffing information on 9/20/2023.
The findings include:
On 9/20/202...
Read full inspector narrative →
Based on observation, staff interview and facility document review, it was determined the facility staff failed to post the nurse staffing information on 9/20/2023.
The findings include:
On 9/20/2023 at 10:29 a.m. an observation of the receptionist desk was conducted. On the desk was the staffing posting, however the paper in the frame was dated 9/19/2023.
An interview was conducted with OSM (other staff member) #2, the receptionist, on 9/20/2023 at 10:31 a.m. When asked who is responsible for putting up the staff posting each day, OSM #2 stated the scheduler usually does it. OSM #2 was asked if the scheduler isn't here, then who puts it up, OSM #2 stated the DON (director of nursing) does it.
An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/20/2023 at 10:32 a.m. When asked who is responsible for posting the staff posting for each day, ASM #2 stated the scheduler was out today and that she is the back up and she didn't do it.
The facility policy, Posting Direct Care Daily Staffing documented in part, Policy: Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Specific Procedures/Guidance: 1. At the beginning of each shift, the number of licensed nurses (RNs -registered nurses, LPNs - licensed practical nurses) and the number of unlicensed nursing personnel (CNAs -certified nursing assistants) directly responsible for resident care will be posted in a prominent location (accessible to resident and visitors) and in a clear and readable format.
ASM #1, the administrator and ASM #2 were made aware of the above finding on 9/20/2023 at 10:35 a.m.
No further information was provided prior to exit.
Jun 2023
8 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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 two of n...
Read full inspector narrative →
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 two of nine residents in the survey sample, Resident #9 and Resident #6.
The findings include:
1. For Resident #9 (R9), the facility staff failed to implement the comprehensive care plan to provide dental services to R9 as needed.
R9's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/10/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section K documented no weight loss in the last month or last six months and the resident receiving a therapeutic diet. Section L documented no mouth pain or dentures.
On 6/20/2023 at 12:25 p.m., an interview was conducted with R9 in their room. R9 stated that they had multiple loose teeth in their mouth and that someone had come in to look inside their mouth but did not do anything. R9 stated that their teeth were painful and made it hard to chew and they had requested to go out to see a dentist multiple times but had no one had never helped them to set up an appointment.
The comprehensive care plan for R9 documented in part, Dental or oral cavity health problem r/t (related to) no natural teeth. Date Initiated: 06/18/2022. Revision on: 01/14/2023. Under Interventions it documented in part, .Refer to dentist/ hygienist for evaluation/ recommendations re: denture realignment, new fitting, teeth pulled, repair of carious teeth as needed. Date Initiated: 06/24/2022. Revision on: 01/11/2023.
The physician orders for R9 documented in part,
- Schedule dentist appointment/refferal [sic] per (name of physician) d/t (due to) sore gums and loose teeth. On hold from 03/31/2022 12:00 to 04/01/2022 00:58 (12:58 a.m.). Order Date: 01/17/2022.
- Schedule Dental visit. On hold from 03/31/2022 12:00 to 04/01/2022 00:58. Order Date: 01/21/2022.
- Dental consult related to sore gums and Loose teeth. Order Date: 04/06/2022.
The progress notes for R9 documented in part,
- 1/17/2022 14:56 (2:56 p.m.) Nutrition/Weight .Note Text : Spoke w/SLP (speech language pathologist) about resident's refusal to consume anything other than liquids. Will drink Ensure, juice, etc. Declined to downgrade diet to pureed. Told SLP his teeth hurt. Writer notified MD (medical doctor), MD stated for nurse to put in order for dental eval. Writer reported MD order to nurse .
- 1/20/2022 14:28 (2:28 p.m.) Nutrition/Weight .Met w/resident in room. Reports difficulty chewing r/t (related to) teeth in poor condition (order in place to make dental appointment in (name of electronic medical record system))
- 1/21/2022 15:34 (3:34 p.m.) Note Text : NP (nurse practitioner) in to see New orders written for CBC, CMP, TSH (complete blood count, comprehensive metabolic panel, thyroid stimulating hormone) next lab day. Dental visit, soft diet until dental appt, start Amoxicillin 500mg TID (three times a day) x 7 days foe [sic] dental infection resident is currently on mechanical sift diet RP (responsible party) is aware of new orderder [sic] and scheduler ids [sic] aware of need for Dental appt. (appointment) and is working on making Appt.
- 7/20/2022 11:45 (11:45 a.m.) Wound Progress note .Daughter expresses concerns for patient's appetite. She feels the decline in PO (by mouth) intake is secondary to issues with his teeth. Stated patient had recently been seen by a dentist in facility with recommendation for extractions. She is unaware if any appointment for further orthodontic
procedure has been scheduled .
- 9/9/2022 15:16 (3:16 p.m.) Note Text : Spoke with resident daughter (Name of daughter) regarding upcoming appointments with dentist, dermatologist and wound clinic. Concerns being addressed with IDT (interdisciplinary) team. (Name of daughter) verbalized satisfaction regarding receiving health updates.
Review of R9's clinical record failed to evidence documentation of dental consults arranged or notes regarding dental care provided.
On 6/20/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of any dental consults and follow up dental visits for R9.
On 6/21/2023 at approximately 9:00 a.m., ASM #2, the director of nursing provided a list of residents including R9 that were scheduled for a visit on 7/6/2023 with the visiting in house dentist. ASM #2 stated that they had searched to try to find a dentist in the community for R9 to go to but they could not find one that could accommodate the resident in their office. ASM #2 stated that they had recently found the new dentist who would come to the facility to see residents but they were unable to come in until 7/6/2023. ASM #2 stated that the medical records staff member arranged outside appointments and did not document what attempts they made or conversations with the resident and the responsible party in the medical record.
On 6/21/2023 at 9:25 a.m., ASM #2 provided a letter dated 6/21/2023 from (Name of outside dental office) stating that they did not accept residents on stretchers. At this time a request was made to ASM #2 for evidence of attempts made prior to 6/21/2023 to set up a dental consultation for R9.
On 6/21/2023 at 9:50 a.m., an interview was conducted with OSM (other staff member) #8, medical records. OSM #8 stated that the nurse practitioner normally let them know when a resident needed an appointment set up outside of the facility and then they reviewed the residents insurance and set up the appointment and transportation accordingly. She stated that they sent some of the residents to (Name of outside dental office) but they did not take residents on stretchers so it was very hard to get appointments for those residents. She stated that the new company starting in July would be able to refer them to someone who would evaluate residents on stretchers. OSM #8 stated that they had attempted to find an outside dental office but did not document the attempts they made. OSM #8 stated that they were solely responsible for finding the resources in the community for the residents and the former social worker did not assist however they were hopeful that the new social worker would assist with this.
On 6/21/2023 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to provide a plan of care for the resident and it should be followed. She stated that she did not remember any dentist visits for R9 and they were not sure if the in house dentist completed a note or a report when they came into the building. She stated that she remembered that R9 had missed some appointments because the transportation did not show up but did not recall which appointments they were. She stated that when a resident required a dentist, they asked the family if they had a dentist in community first and if not they asked the physician who they recommended and the scheduler set up the appointment.
On 6/21/2023 at 12:18 p.m., an interview was conducted with ASM #2, director of nursing. ASM #2 stated that they had been at the facility since June of 2022. ASM #2 stated that R9 had never complained to the staff about having issues with their teeth and they had we offered to set up an appointment however it was challenging because the one that they had contracted with could not see him and the one they found that would take his insurance would not accommodate his stretcher. ASM #2 stated that they had been attempting to set up the appointment since they had discussed it with the daughter on 9/9/2022 and it was challenging for them because there were few dentists that would do mobile visits. ASM #2 stated that the documentation was where the missing piece was because the medical records staff did not document. ASM #2 stated that they thought that the former social worker had gotten involved and attempted to find resources also but they did not have any documentation to evidence that.
The facility policy Care Planning- Interdisciplinary Team undated, failed to evidence guidance on implementing the care plan.
On 6/21/2023 at 4:06 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
2. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan for administering medications per the physician orders.
The comprehensive care plan revised on 1/31/2023, documented in part, Focus: The resident is on insulin r/t (related to) diabetes. Focus: At risk for change in mood r/t anxiety and depression. Focus: At risk for changes in mood r/t depression. Focus: Cardiac disease related to hyperlipidemia, hypertension. Focus: Endocrine System related to diabetes. Focus: Neurological deficiencies related to seizure. Focus: Pain related to generalized pain and back pain, shoulder pain, vaginal pain, leg pain. For all these focused areas on the care plan the Intervention document in part, Administer medications per physician orders.
The physician order summary for March/April 2023 documented the physician orders for the following medications:
1. Atorvastatin Calcium Tablet (1) 40 mg (milligrams); Give 40 mg by mouth at bedtime for Hyperlipidemia (elevated fats in blood).
2. Basaglar KwikPen Solution (2) Injector 100 UNIT/ML (units per milliliter) (Insulin Glargine); inject 70 units subcutaneously at bedtime for diabetes.
3. Clonazepam Tablet Disintegrating (3) 0.125 mg; Give 1 tablet by mouth two times a day related to anxiety disorder.
4. Insulin Lispro Solution (4): inject as per sliding scale if bs (blood sugar) 150-200 = 4 units, 201 -250 = 6 units, 251 - 300 = 8 units, 301-350 = 10 units, 351 - 400 = 12 units before meals and at bedtime for diabetes.
5. Lidocaine patch (5) 5%; apply to foot - dorsal (top) left topically one tine a da for pain remove after 12 hours.
6. Melatonin Oral 3 mg Tablet (6); Give 6 mg by mouth at bedtime for insomnia.
7. Metformin HCL (7) 500 mg; Give 1000 mg by mouth at bedtime for DM (diabetes mellitus).
8. Metformin HCL 500 mg: Give 500 mg by mouth one time a day for DM.
9. Oxybutynin CL ER (extended release) 10 mg Tablet (8); Give 1 tablet by mouth at bedtime for OAB (overactive bladder).
10. OxyContin Tablet ER 10 mg (9); Give 10 mg by mouth every 12 hours related to: Encounter for orthopedic aftercare following surgical amputation.
11. Ramelteon Oral Tablet (10) 8 mg; Give 8 mg by mouth at bedtime for insomnia.
12. Seroquel Tablet 25 mg (11); Give 1 tablet by mouth two times day for Bipolar Disorder.
13. Topiramate Tablet 25 mg (12); Give 25 mg by mouth two times a day for seizure.
The March 2023 MAR (medication administration record) documented the above orders. On 3/31/2023, the following medications had a blank where the nurse should sign that the medication was given:
Atorvastatin Calcium - due at 9:00 p.m.
Basaglar KwikPen Solution - a blood sugar and administration was due at 9:00 p.m.
Melatonin Oral Tablet - due at 9:00 p.m.
Metformin HCL tablet 1000 mg - due at 9:00 p.m.
Oxybutynin CL ER 10 mg - due at 9:00 p.m.
Ramelteon Oral Tablet 8 mg - due at 9:00 p.m.
Oxycontin Tablet ER 10 mg - due at 9:00 p.m.
Insulin Lispro solution - inject per the sliding scale - due at 9:00 p.m.
The April 2023 MAR documented the above orders. On 4/12/2023, the following medications had a blank where the nurse should sign that the medication was given:
Lidocaine Patch 5% - due at 9:00 a.m.
Metformin HCL tablet 500 mg - due at 9:00 a.m.
Oxycontin Oral Tablet ER 15 mg - due at 9:00 a.m.
Seroquel Tablet 25 mg - due at 9:00 a.m.
Clonazepam Tablet 0.125 mg - due at 9:00 a.m.
Topiramate Tablet 25 mg - due at 9:00 a.m.
Gabapentin 100 mg - 2 capsules - due at 9:00 a.m. and 1:00 p.m.
Insulin Lispro Solution - due at 11:10 a.m. with no blood sugar documented.
An interview was conducted with LPN (licensed practical nurse) #1 on 6/21/2023 at 11:10 a.m. When asked the purpose of the care plan LPN #1 stated it's the plan of care for the resident. LPN #1 was asked if the care plan should be followed, LPN #1 stated, yes.
ASM #1, the administrator, ASM #2 and ASM #4, the regional nurse consultant, were made aware of the above concern on 6/21/2023 at 4:45 p.m.
No further information was provided prior to exit.
References:
(1) Atorvastatin is given to lower lipids (fats) in the blood stream. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600045.html
(2) Basalar KwikPen Insulin Glargine is used to treat diabetes, it's a long-acting insulin. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600027.html
(3) Clonazepam is used to treat seizures and panic attacks. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682279.html
(4) Insulin Lispro is a short acting insulin used to treat diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021.html
(5) Lidocaine Patch is used to treat pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603026.html
(6) Melatonin is used to treat insomnia. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/940.html
(7) Metformin is used to treat diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a696005.html
(8) Oxybutynin is used to treat overactive bladder. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682141.html
(9) Oxycontin is used to treat moderate to severe pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html
(10) Ramelteon is used to insomnia. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a605038.html
(11) Seroquel is used to treat schizophrenia and depression. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a605038.html
(12) Topiramate is used to treat seizures. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697012.html
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 resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications per the physician orders for on...
Read full inspector narrative →
Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications per the physician orders for one of nine residents in the survey sample, Resident #6.
The findings include:
For Resident #6 (R6), the facility staff failed to administer the morning medications on 4/12/2023, and the evening medications on 3/31/2023, and failed to administer medications on 6/19/2023 within the prescribed time frame.
An interview was conducted with R6 on 6/20/2023 at 2:10 p.m. R6 stated that on 4/12/2023 the nurse never gave her, her morning medications and there was another time in March she didn't get her medications. R6 also stated that on 6/19/2023 they received her morning medications at almost 1:00 p.m.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/2/2023, the resident scored 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.
The physician order summary for March/April/June 2023 documented the physician orders for the following medications:
1. Atorvastatin Calcium Tablet (1) 40 mg (milligrams); Give 40 mg by mouth at bedtime for Hyperlipidemia (elevated fats in blood).
2. Basaglar KwikPen Solution (2) Injector 100 UNIT/ML (units per milliliter) (Insulin Glargine); inject 70 units subcutaneously at bedtime for diabetes.
3. Clonazepam Tablet Disintegrating (3) 0.125 mg; Give 1 tablet by mouth two times a day related to anxiety disorder.
4. Insulin Lispro Solution (4): inject as per sliding scale if bs (blood sugar) 150-200 = 4 units, 201 -250 = 6 units, 251 - 300 = 8 units, 301-350 = 10 units, 351 - 400 = 12 units before meals and at bedtime for diabetes.
5. Lidocaine patch (5) 5%; apply to foot - dorsal (top) left topically one tine a da for pain remove after 12 hours.
6. Melatonin Oral 3 mg Tablet (6); Give 6 mg by mouth at bedtime for insomnia.
7. Metformin HCL (7) 500 mg; Give 1000 mg by mouth at bedtime for DM (diabetes mellitus).
8. Metformin HCL 500 mg: Give 500 mg by mouth one time a day for DM.
9. Oxybutynin CL ER (extended release) 10 mg Tablet (8); Give 1 tablet by mouth at bedtime for OAB (overactive bladder).
10. OxyContin Tablet ER 10 mg (9); Give 10 mg by mouth every 12 hours related to: Encounter for orthopedic aftercare following surgical amputation.
11. Ramelteon Oral Tablet (10) 8 mg; Give 8 mg by mouth at bedtime for insomnia.
12. Seroquel Tablet 25 mg (11); Give 1 tablet by mouth two times day for Bipolar Disorder.
13. Topiramate Tablet 25 mg (12); Give 25 mg by mouth two times a day for seizure.
The March 2023 MAR (medication administration record) documented the above orders. On 3/31/2023, the following medications had a blank where the nurse should sign that the medication was given:
Atorvastatin Calcium - due at 9:00 p.m.
Basaglar KwikPen Solution - a blood sugar and administration was due at 9:00 p.m.
Melatonin Oral Tablet - due at 9:00 p.m.
Metformin HCL tablet 1000 mg - due at 9:00 p.m.
Oxybutynin CL ER 10 mg - due at 9:00 p.m.
Ramelteon Oral Tablet 8 mg - due at 9:00 p.m.
Oxycontin Tablet ER 10 mg - due at 9:00 p.m.
Insulin Lispro solution - inject per the sliding scale - due at 9:00 p.m.
The April 2023 MAR documented the above orders. On 4/12/2023, the following medications had a blank where the nurse should sign that the medication was given:
Lidocaine Patch 5% - due at 9:00 a.m.
Metformin HCL tablet 500 mg - due at 9:00 a.m.
Oxycontin Oral Tablet ER 15 mg - due at 9:00 a.m.
Seroquel Tablet 25 mg - due at 9:00 a.m.
Clonazepam Tablet 0.125 mg - due at 9:00 a.m.
Topiramate Tablet 25 mg - due at 9:00 a.m.
Gabapentin 100 mg - 2 capsules - due at 9:00 a.m. and 1:00 p.m.
Insulin Lispro Solution - due at 11:10 a.m. with no blood sugar documented.
The June 2023 MAR documented the above orders. On 6/19/2023, the following medications were documented on the Medication Administration Audit Report as being administered between 12:42 and 12:51 p.m.
Seroquel Tablet 25 mg - due at 9:00 a.m.
Clonazepam Tablet 0.125 mg - due at 9:00 a.m.
Oxycontin Oral Tablet ER 15 mg - due at 9:00 a.m.
Metformin HCL tablet 500 mg - due at 9:00 a.m.
Insulin Lispro Solution - due at 11:30 a.m. Blood sugar documented - 188 - documented as done at 12:50 p.m.
The comprehensive care plan revised on 1/31/2023, documented in part, Focus: The resident is on insulin r/t (related to) diabetes. Focus: At risk for change in mood r/t anxiety and depression. Focus: At risk for changes in mood r/t depression. Focus: Cardiac disease related to hyperlipidemia, hypertension. Focus: Endocrine System related to diabetes. Focus: Neurological deficiencies related to seizure. Focus: Pain related to generalized pain and back pain, shoulder pain, vaginal pain, leg pain. For all of these focused areas on the care plan the Intervention document in part, Administer medications per physician orders.
On 6/21/2023 at 8:46 a.m. ASM (administrative staff member) #2, the director of nursing, was asked who the nurse responsible for the administration of medications to R6 on 4/12/2023, on the morning shift was. ASM #2 stated, Those medications were missed. I received a call from one of the nurses to inform me that (R6) did not receive her morning medications. Upon her investigation, ASM #2 stated the nurse that was assigned to R6 claimed she didn't know the resident was her patient. ASM #2 stated that the unit manager administered as many of the medications that could be given without overlap of medications or times. That's why there are still blanks on the MAR.
On 6/21/2023 at 9:31 a.m., an interview was conducted with ASM #2 regarding the missing medications on 3/31/2023. ASM #2 stated it was an agency nurse. The nurse was working a double and gave the morning medications but can't say if she gave the evening medications. When asked if there is a blank on the MAR, what does that indicate, ASM #2 stated, if it's not documented it most likely was not given. ASM #2 was asked about the times of the morning medications given on 6/19/2023. ASM #2 stated she could not get in contact with the nurse that administered the medications on 6/19/2023.
The facility policies provided, Medication and Treatment Orders and Medication Orders failed to evidence documentation and administration of medications per the physician orders.
ASM #1, the administrator, ASM #2 and ASM #4, the regional nurse consultant, were made aware of the above concern on 6/21/2023 at 4:45 p.m.
No further information was provided prior to exit.
References:
(1) Atorvastatin is given to lower lipids (fats) in the blood stream. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600045.html
(2) Basalar KwikPen Insulin Glargine is used to treat diabetes, it's a long-acting insulin. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600027.html
(3) Clonazepam is used to treat seizures and panic attacks. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682279.html
(4) Insulin Lispro is a short acting insulin used to treat diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021.html
(5) Lidocaine Patch is used to treat pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603026.html
(6) Melatonin is used to treat insomnia. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/940.html
(7) Metformin is used to treat diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a696005.html
(8) Oxybutynin is used to treat overactive bladder. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682141.html
(9) Oxycontin is used to treat moderate to severe pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html
(10) Ramelteon is used to insomnia. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a605038.html
(11) Seroquel is used to treat schizophrenia and depression. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a605038.html
(12) Topiramate is used to treat seizures. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697012.html
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, family interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of nine residents were fr...
Read full inspector narrative →
Based on resident interview, staff interview, family interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of nine residents were free from a significant medication error, Resident #6.
The findings include:
For Resident #6 (R6), the facility staff gave the morning medications and the 1:00 p.m. medications at the same time, causing resident to be very drowsy for the rest of the day.
An interview was conducted with R6 on 6/20/2023 at 2:10 p.m. R6 stated on 6/19/2023 the nurse gave them, their 9:00 a.m. medications and their 2:00 p.m. medications at the same time at a little before 1:00 p.m. R6 stated it included four capsules of Gabapentin. R6 stated they did not wake up until midnight. R6 recalled asking the night CNA (certified nursing assistant) why she was there so early. The CNA told R6 it was midnight. R6's family was in the room and stated they could not get in touch with R6 all day and was getting ready to come to the facility when they did get a hold of them later in the evening but stated R6 was out of it.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/2/2023, the resident scored 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.
Review of the physician orders dated 9/28/2021, documented, Gabapentin Capsule (1)100 mg; give 2 capsules by mouth three times a day for neuropathic pain.
The MAR (medication administration record) for June 2023, documented the resident was due to receive Gabapentin 100 mg - 2 tablets scheduled for 9:00 a.m. and Gabapentin 100 mg - 2 capsules, scheduled for 1:00 p.m.
Review of the Medication Administration Audit Report revealed the 9:00 a.m. and 1:00 p.m. doses of Gabapentin were administered at 12:42 p.m. and 12:49 p.m.
The nurse who administered the medications on 6/19/2023 was unable to be reached during the survey.
An interview was conducted with LPN (licensed practical nurse) #1, on 6/21/2023 at 11:10 a.m. When asked if a nurse can give two doses of a medication at once, an example of 9:00 a.m. and 1:00 p.m. dose together, LPN #1 stated, you shouldn't.
On 6/21/2023 at 11:45 a.m., an interview was conducted with ASM #3, the attending physician for R6. The Gabapentin order and the times given were explained to ASM #3. When asked if two doses of a medication should be given at the same time, ASM #3 stated no. ASM #3 was asked if two doses of Gabapentin were given at the same time, what effect would it have on the resident, ASM #3 stated the resident would be very groggy and dizzy. ASM #3 stated, If the resident missed a dose in the morning, then the nurse should have called me for directions. Two doses should not be given at one time.
An interview was conducted with ASM #2, the director of nursing, on 6/21/2023 at 11:59 a.m. When asked if a nurse can give two doses of Gabapentin at one time, ASM #2 stated no, there are parameters set by the physician for each medication, be it every day, every eight hours, or every 12 hours. The physician orders should be followed. When the above was explained, ASM #2 stated the resident is alert and oriented and knows what is going on. ASM #2 stated the resident will ask what she is receiving and usually pops all pills in her mouth at one time.
The facility policies provided, Medication and Treatment Orders and Medication Orders failed to evidence documentation and administration of medications per the physician orders.
On 6/21/2023 at 4:45 p.m., ASM #1, the administrator, ASM #2 and ASM #4, the regional nurse consultant, were made aware of the above concern.
No further information was provided prior to exit.
(1) Gabapentin is used to treat seizures and pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a694007.html.
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 F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide radiological services in a timely manner to one of nine residents...
Read full inspector narrative →
Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide radiological services in a timely manner to one of nine residents in the survey sample, Resident #5.
The findings include:
For Resident #5 (R5), the facility staff failed to obtain a physician ordered STAT (urgent) x-ray for approximately 18 hours after the order was documented. The resident was in pain with a swollen leg and could not be repositioned due to the pain as documented in the clinical record.
The nurse's note, written by LPN #1, dated 7/3/2022 at 10:20 a.m. documented, Writer was called to room along with another staff member. Resident was noted lying on her left side facing door, resident back was at window. When assessing resident, writer observed left leg was extremely swollen from above left knee down left foot. Resident left leg was contracted up, unable to move leg. Writer also observed dark purple discoloration on left calf. When touching the left leg starting at foot, and coming up the leg, resident started to do facial grimacing, when touching below left knee and above the knee. Another staff member was assigned to the resident, the nurse was present.
The nurse's note, written by RN (registered nurse) #1, dated, 7/3/2022 at 12:37 p.m. documented, Resident was assessed due to change in condition, specifically the swelling of entire lower extremity and bruising noted to posterior left leg, as pointed out by her aide and then reported to the nurse. Resident is a [name of hospice company] Hospice patient and this nurse contacted the nurse on-call to obtain orders. The on-call nurse contacted the MD (medical doctor) on-call and an x-ray to the patient's left hip and left knee was ordered. Confirmation number 37301093. The resident only complained of pain with touch, but is resting comfortably and without visible s/s (signs and symptoms) of pain at this time. Administrator contacted via text, then replied via phone call to this nurse. The family was contacted by the hospice nurse and they agreed to the x-ray. Will report to next shifts and then follow up upon completion of x-ray.
The physician order dated, 7/3/2022 at 11:46 a.m. documented, X-ray to left hip and left knee to rule out fracture. STAT. Indication: pain and swelling.
The nurse's note dated, 7/4/2022 at 12:09 a.m. documented, Chart check done new order noted. X-ray to LEFT hip and LEFT knee to rule out fracture. STAT for pain and swelling.
The X-ray report dated 7/4/2022, documented the x-ray was taken at 5:50 a.m. and reported to the facility at 8:53 a.m.
The nurse's note dated, 7/4/2022 at 6:51 a.m. documented, X-ray tech (technician) in and taken x-rays as ordered.
The nurse's note dated, 7/4/2022 at 8:28 a.m. documented, Resident was received lying in bed on her left side. Bruising noted to abdomen and leg on left side. LEFT LEG IS TRIPLE IN SIZE OF NORMAL, PAINFUL TO TOUCH. Morphine 0.25 mg (milligrams) given for pain. Staff is unable to reposition due to pain level. Hospice nurse was notified and will send nurse to assessment resident. (Name of x-ray company) was called for x-ray results. Results are not available at this time.
RN #1 was no longer employed by the facility and unavailable for interview. The CNA that discovered the swelling and bruising of the left leg was no longer employed by the facility and was unavailable for interview.
An interview was conducted with LPN #1 on 6/21/2023 at 11:06 a.m. When asked the process to get a physician ordered x-ray, LPN #1 stated you get the order, call the company and give them a copy of the order and the face sheet when they come. LPN #1 was asked what time frame would she expect the x-ray company to come, LPN #1 stated, within four hours.
An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 6/21/2023 at 11:59 a.m. When asked if there is an order for a STAT x-ray, when should it be done, ASM #2 stated she believed the contract is for it to be completed within four to six hours. When asked what happened on 7/3/2022 for R5, ASM #2 stated she was in orientation and there was an interim DON (director of nursing) here and she handled this. ASM #2 further stated, if she couldn't get the mobile company to get here, she would have contacted the doctor to send the resident out to the emergency room for evaluation.
An interview was conducted with LPN #2 on 6/21/2023 at 1:50 p.m. LPN #2's nurse's note from 7/3/2022 was reviewed with her. When asked to explain what happened that day, LPN #2 stated, (R5) wasn't my resident. The CNA said her leg was swollen and painful to touch and was hollering out when you tried to move it. I went in. The left leg was swollen from the thigh to the foot and contracted. (R5) couldn't move it. I palpated the leg and when I got to the knee it was very painful, (R5) was hollering out. There was dark purple discoloration on the back of the leg. I told their nurse, and their nurse and I went in to see resident together. When asked is the resident normally contracted, LPN #2 stated, no, the resident sits in the wheelchair and propels around the facility. LPN #2 stated she had seen R5 the previous day in the day room.
The contract for the Provider for X-ray Services, documented in part, 1.1 Provide Center with complete, accurate and timely Services upon the request of the Center in accordance with the orders of a patient's attending physician .1.3 Be available to provide Services 24 hours a day, 7 days a week for rush or stat tests and any significant abnormal findings.
The facility policy, Radiology and Diagnostic Services documented in part, POLICY: Radiological and diagnostic testing services are provided the facility to meet the needs of our residents. The service may be provided on-site or off-site through contracted services of a diagnostic testing provider that is approved to provide the services by Medicare. DEFINITIONS: Radiology Services: Radiology is the medical discipline that uses medical imaging to diagnose and treat diseases. A variety of imaging techniques such as X-ray radiography, ultrasound, computed tomography (CT), nuclear medicine including positron emission tomography (PET), fluoroscopy, and magnetic resonance imaging (MRI) are used to diagnose or treat diseases. SPECIFIC PROCEDURES / GUIDANCE: 1.The facility will enter into written contracts and agreements to ensure that appropriate radiological and diagnostic testing is available to the residents as ordered by the physician / practitioner. a.The service may be provided on-site or off-site through contracted services of a diagnostic testing provider that is approved to provide the services by Medicare. b.The radiological services may be provided at the facility through contract for mobile services or the resident may be transported to a location in which the radiological diagnostic testing can be performed.
ASM #1, the administrator, ASM #2 and ASM #4, the regional nurse consultant, were made aware of the concern on 6/21/2023 at 2:45 p.m. for the delay in obtaining a physician ordered STAT x-ray in a timely manner.
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 F0779
(Tag F0779)
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 ensure radiology results were included in the medical record for one ...
Read full inspector narrative →
Based on staff interview, clinical record review, and facility document review it was determined that the facility staff failed to ensure radiology results were included in the medical record for one of nine residents in the survey sample, Resident #9.
The findings include:
For Resident #9 (R9), the facility staff failed to ensure an MRI (magnetic resonance imaging) report completed on 4/3/2023 was included in the medical record.
The progress notes for R9 documented in part;
- 3/2/2023 13:00 (1:00 p.m.) Medical Practitioner Note (Physician/NP (nurse practitioner)) .Plan: acute- related symptoms cyclic episodes of stumbling of words, upper extremity tremor that last less than 5 seconds each episode. These episodes have occurred in the past and resolved within 3 to 4 days per patient. Patients remain AOX4 (alert and oriented to person, place, time and situation) during episodes. intermittent dysphagia (1) when episodes occur. MRI scheduled 3/17, neurology consult 3/22 .
- 3/17/2023 21:56 (9:56 p.m.) Nurses note. Note Text : Paperwork was placed in scheduler's box for appt to be rescheduled due to the transportation not picking up resident earlier for appt (appointment). Transportation company stated that they didn't have a driver.
- 4/3/2023 14:09 (2:09 p.m.) Note Text : Resident returned from appt at 9:00am. No concerns expressed. No new orders.
Review of R9's clinical record failed to evidence results from the scheduled MRI.
On 6/20/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of neurology consults and MRI completed in March of 2023.
On 6/21/2023 at 10:35 a.m., ASM #1 stated that the nurse practitioner who worked with R9 was not available to be interviewed.
On 6/21/2023 at approximately 1:00 p.m., ASM #1 provided evidence of the MRI being performed on 4/3/2023 at 7:41 a.m. with results documented as in process.
On 6/21/2023 at 11:58 a.m., an interview was conducted with ASM #3, medical doctor. ASM #3 stated that in their records it documented an MRI back in 2019 but they did not recall anything recently. She stated that (R9) had mentioned to the nurse practitioner that he had memory issues, and they had examined him the previous week and were not aware of an MRI being done recently.
On 6/21/2023 at approximately 4:00 p.m., a request was made to ASM #1 for the MRI results and evidence of physician review.
On 6/22/2023 at 8:25 a.m., ASM #1 stated that they did not have the results of the MRI. ASM #1 stated that the original MRI results were given to the nurse practitioner who had them prior to going out on leave. ASM #1 stated that the results should be in the clinical record.
On 6/22/2023 at 8:55 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that normally they relied on the physician, the nurse practitioner or medical records staff to obtain the results of radiology tests completed at outside facilities. She stated that they sent an order to the facility when the appointment was made and with the resident the day of the appointment and the facility normally faxed the results to them within 24-72 hours afterwards. LPN #1 stated that anything urgent was called to the physician or nurse practitioner any other results were placed in the medical record for review.
On 6/22/2023 at 9:14 a.m., ASM #2, the director of nursing provided a faxed copy of the MRI results from 4/3/2023 with a faxed date of 6/22/2023 at 8:05 a.m. She stated that the results were on the record and the nurse practitioner had reviewed them and discussed them with the resident and the family already but they had gotten misplaced and they were unable to provide evidence that the report was in the medical record so they had another copy faxed to put in the medical record.
The facility policy Radiology and Diagnostic Services undated, documented in part, .Radiological and diagnostic testing services are provided the facility to meet the needs of our residents. The service may be provided on-site or off-site through contracted services of a diagnostic testing provider that is approved to provide the services by Medicare The facility will file in the resident's clinical record diagnostic reports that are dated and contain the name and address of the testing facility .
The facility policy Content and Order of Medical Record undated, documented in part, .The medical record will include: .h. Laboratory and diagnostic reports .
On 6/22/2023 at 8:38 a.m., ASM #1, the administrator was made aware of the concern.
No further information was provided prior to exit.
Reference:
(1) dysphagia- A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.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
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
Based on resident interview, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to provide dental services for one of nine residents...
Read full inspector narrative →
Based on resident interview, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to provide dental services for one of nine residents in the survey sample, Resident #9.
The findings include:
For Resident #9 (R9), the facility staff failed to provide a dental consult first ordered on 1/17/2022, and again on 1/21/2022 and 4/6/2022.
R9's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/10/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section K documented no weight loss in the last month or last six months and the resident receiving a therapeutic diet. Section L documented no mouth pain or dentures.
The clinical record documented R9 under Medicare A services at the facility from 10/15/2021-11/8/2021, 4/4/2022-6/9/2022, and 6/17/2022-7/23/2022; Medicaid services from 11/9/2021- 4/3/2022 and United Healthcare Commonwealth Coordinated Care Plus services from 7/24/2022-6/7/2023.
On 6/20/2023 at 12:25 p.m., an interview was conducted with R9 in their room. R9 stated that they had multiple loose teeth in their mouth and that someone had come in to look inside their mouth but did not do anything. R9 stated that their teeth were painful and made it hard to chew and they had requested to go out to see a dentist multiple times but had no one had never helped them to set up an appointment.
The comprehensive care plan for R9 documented in part, Dental or oral cavity health problem r/t (related to) no
natural teeth. Date Initiated: 06/18/2022. Revision on: 01/14/2023. Under Interventions it documented in part, .Refer to dentist/ hygienist for evaluation/ recommendations re: denture realignment, new fitting, teeth pulled, repair of carious teeth as needed. Date Initiated: 06/24/2022. Revision on: 01/11/2023.
The physician orders for R9 documented in part,
- Schedule dentist appointment/refferal [sic] per (name of physician) d/t (due to) sore gums and loose teeth. On hold from 03/31/2022 12:00 to 04/01/2022 00:58 (12:58 a.m.). Order Date: 01/17/2022.
- Schedule Dental visit. On hold from 03/31/2022 12:00 to 04/01/2022 00:58. Order Date: 01/21/2022.
- Dental consult related to sore gums and Loose teeth. Order Date: 04/06/2022.
- Amoxicillin Capsule 500 MG (milligram) Give 500 mg by mouth three times a day for mouth pain for 7 Days. Order Date: 01/21/2022.
The progress notes for R9 documented in part,
- 1/17/2022 14:56 (2:56 p.m.) Nutrition/Weight .Note Text : Spoke w/SLP (speech language pathologist) about resident's refusal to consume anything other than liquids. Will drink Ensure, juice, etc. Declined to downgrade diet to pureed. Told SLP his teeth hurt. Writer notified MD (medical doctor), MD stated for nurse to put in order for dental eval. Writer reported MD order to nurse .
- 1/20/2022 14:28 (2:28 p.m.) Nutrition/Weight .Met w/resident in room. Reports difficulty chewing r/t (related to) teeth in poor condition (order in place to make dental appointment in (name of electronic medical record system))
- 1/21/2022 15:34 (3:34 p.m.) Note Text : NP (nurse practitioner) in to see New orders written for CBC, CMP, TSH (complete blood count, comprehensive metabolic panel, thyroid stimulating hormone) next lab day. Dental visit, soft diet until dental appt, start Amoxicillin 500mg TID (three times a day) x 7 days foe [sic] dental infection resident is currently on mechanical sift diet RP (responsible party) is aware of new orderder [sic] and scheduler ids [sic] aware of need for Dental appt. (appointment) and is working on making Appt.
- 4/26/2022 23:21 (11:21 p.m.) admit/readmit .Has teeth missing in the mouth no dentures or other dental apparatus .
- 7/20/2022 11:45 (11:45 a.m.) Wound Progress note .Daughter expresses concerns for patient's appetite. She feels the decline in PO (by mouth) intake is secondary to issues with his teeth. Stated patient had recently been seen by a dentist in facility with recommendation for extractions. She is unaware if any appointment for further orthodontic
procedure has been scheduled .
- 9/9/2022 15:16 (3:16 p.m.) Note Text : Spoke with resident daughter (Name of daughter) regarding upcoming appointments with dentist, dermatologist and wound clinic. Concerns being addressed with IDT (interdisciplinary) team. (Name of daughter) verbalized satisfaction regarding receiving health updates.
Review of R9's clinical record failed to evidence documentation of dental consults arranged or notes regarding dental care provided.
On 6/20/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of any dental consults and follow up dental visits for R9.
On 6/21/2023 at approximately 9:00 a.m., ASM #2, the director of nursing provided a list of residents including R9 that were scheduled for a visit on 7/6/2023 with the visiting in house dentist. ASM #2 stated that they had searched to try to find a dentist in the community for R9 to go to but they could not find one that could accommodate the resident in their office. ASM #2 stated that they had recently found the new dentist who would come to the facility to see residents but they were unable to come in until 7/6/2023. ASM #2 stated that the medical records staff member arranged outside appointments and did not document what attempts they made or conversations with the resident and the responsible party in the medical record.
On 6/21/2023 at 9:25 a.m., ASM #2 provided a letter dated 6/21/2023 from (Name of outside dental office) stating that they did not accept residents on stretchers. At this time a request was made to ASM #2 for evidence of attempts made prior to 6/21/2023 to set up a dental consultation for R9.
On 6/21/2023 at 9:50 a.m., an interview was conducted with OSM (other staff member) #8, medical records. OSM #8 stated that the nurse practitioner normally let them know when a resident needed an appointment set up outside of the facility and then they reviewed the residents insurance and set up the appointment and transportation accordingly. She stated that they sent some of the residents to (Name of outside dental office) but they did not take residents on stretchers so it was very hard to get appointments for those residents. She stated that the new company starting in July would be able to refer them to someone who would evaluate residents on stretchers. OSM #8 stated that they had attempted to find an outside dental office but did not document the attempts they made. OSM #8 stated that they were solely responsible for finding the resources in the community for the residents and the former social worker did not assist however they were hopeful that the new social worker would assist with this.
On 6/21/2023 at 10:35 a.m., ASM #1 stated that the nurse practitioner who worked with R9 was not available to be interviewed.
On 6/21/2023 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they did not remember any dentist visits for R9 and they were not sure if the in house dentist completed a note or a report when they came into the building. She stated that she remembered that R9 had missed some appointments because the transportation did not show up but did not recall which appointments they were. She stated that when a resident required a dentist, they asked the family if they had a dentist in community first and if not they asked the physician who they recommended and the scheduler set up the appointment.
On 6/21/2023 at 11:58 a.m., an interview was conducted with ASM #3, medical doctor. ASM #3 stated that they had not been advised of R9 needing to be seen by a dentist and staff had never contacted them about any dental concerns.
On 6/21/2023 at 12:18 p.m., an interview was conducted with ASM #2, director of nursing. ASM #2 stated that they had been at the facility since June of 2022. ASM #2 stated that R9 had never complained to the staff about having issues with their teeth and they had we offered to set up an appointment however it was challenging because the one that they had contracted with could not see him and the one they found that would take his insurance would not accommodate his stretcher. ASM #2 stated that they had been attempting to set up the appointment since they had discussed it with the daughter on 9/9/2022 and it was challenging for them because there were few dentists that would do mobile visits. ASM #2 stated that the documentation was where the missing piece was because the medical records staff did not document. ASM #2 stated that they thought that the former social worker had gotten involved and attempted to find resources also but they did not have any documentation to evidence that.
On 6/21/2023 at 11:27 a.m., an interview was conducted with OSM #9, social services director. OSM #9 stated that they had been at the facility since the end of May 2023. OSM #9 stated that they were still learning the process but any outside physician appointments were handled by the scheduler. OSM #9 stated that they assisted with psychiatric consults, discharge planning, home health consults and outside physician appointments were not handled by social services.
The facility policy Dental consultant undated, documented in part, .The facility may make a referral to a Consultant Dentist who is responsible for: a. Providing consultation to physicians and providing other services relative to dental matters; b. Providing a dental assessment of each resident as needed .
On 6/21/2023 at 4:06 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record, for one of nine residen...
Read full inspector narrative →
Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record, for one of nine residents in the survey sample, Resident #7.
The findings include:
For Resident #7 (R7), the facility staff failed to accurately document the continence status of R7 on the ADL (activities of daily living) documentation for September and October 2022. They documented the resident was continent when the resident had an indwelling urinary catheter.
On the MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/25/2022, the resident was coded in Section H - Bladder and Bowel as having an indwelling catheter.
The physician order dated, 8/8/2022, documented, Maintain Foley 18 Fr (French) catheter every shift.
The comprehensive care plan dated 5/17/2022, documented in part, Focus: Use of indwelling urinary catheter needed due to neuromuscular dysfunction of bladder.
The code for reading the ADL documentation: IN = incontinent; C - continent; 3 = Continence not rated due to indwelling catheter.
The September 2022 ADL document form documented under Toileting the following:
IN was documented on 13 out of 90 shifts.
C was documented o 29 out of 90 shifts.
3 was documented on 47 out of 90 shifts.
The October 2022 ADL document form documented under Toileting the following:
IN was documented on four of 93 shifts,
C was documented on 30 of 93 shifts.
3 was documented on 53 of 93 shifts.
An interview was conducted with CNA # 1 on 6/22/2023 at 8:45 a.m. The above ADL documentation was reviewed with CNA #1. When asked if R7 is continent of urine, CNA #1 stated, no, (R7) has a catheter. CNA #1 stated she doesn't know how the C or 3 or IN gets in the system but for R7 she just clicks the resident has an indwelling catheter. CNA #1 was asked if the documentation above was correct, CNA #1 stated, no.
On 6/22/2023 at 9:06 a.m., the above ADL documentation was reviewed with ASM (administrative staff member) #2, the director or nursing. When asked if the documentation was correct, ASM #2 stated, no.
The facility policy, Content and Order of Medical Record documented in part, POLICY: The resident's medical records shall be complete and assembled in a systematic order. The facility policy, Activities of Daily Living failed to evidence documentation related to the documentation of the ADLs.
ASM #1, the administrator, and ASM #4, the regional nurse consultant, were made aware of the above concern on 6/22/2023 at 9:10 a.m.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected multiple residents
Based on staff interview and facility document review it was determined that the facility staff failed to employ a qualified full-time social worker from 2/24/2023 through 5/24/2023.
The findings incl...
Read full inspector narrative →
Based on staff interview and facility document review it was determined that the facility staff failed to employ a qualified full-time social worker from 2/24/2023 through 5/24/2023.
The findings include:
On 6/20/2023 at approximately 11:14 a.m. during entrance conference with ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing, ASM #1 stated that the facility had 128 beds.
Review of the resident council minutes documented in part;
- Resident council minutes Date: 2/24/23 . No Social Worker currently .
- Resident council minutes Date: 3/22/24 [sic] (3/22/23) . Still without social worker at this time, (Name of activities director and rehab director) helping to cover. Concerns: (Name of 3 residents) requesting a SW (social worker) visit .
- Resident council minutes Date: 4/19/23 . Still without social worker at this time, (Name of activities director and rehab director) helping to cover .
- Resident council minutes Date: 5/17/23 . Still without social worker at this time, (Name of activities director and rehab director) helping to cover .
On 6/21/2023 at approximately 11:18 a.m., a request was made to ASM #1 for evidence of a full-time social worker employed at the facility between February 2023 through May 2023.
On 6/21/2023 at 1:12 p.m., ASM #1 provided employment information for the former social worker documenting a termination date of 2/23/2023 and a status change notice documenting a transfer date for OSM (other staff member) #9, (the current social service director) of 5/25/2023. ASM #1 stated that they had access to OSM #9 at their sister facility but did not have anyone in the position full time in the building and had assigned different department managers tasks related to the position during the vacancy.
On 6/21/2023 at 1:36 p.m., an interview was conducted with OSM #7, activities director. OSM #7 stated that when they did not have a social worker in the building they were helping to oversee the running of care plan meetings, doing the BIMS (brief interview for mental status) and PHQ9 (questionnaire for depression) assessments for the MDS (minimum data set) and the rehab director was helping with discharge planning.
On 6/21/2023 at 11:27 a.m., an interview was conducted with OSM #9, social service director. OSM #9 stated that they had worked at the facility full time since the end of May 2023 and there was no social worker at the facility when they started working at the facility.
The facility policy Social Services undated, documented in part, .1. The Director of Social Services is a qualified social worker and is responsible for: a. Consultation with other departments regarding program planning, policy development, and priority setting of social services .
On 6/21/2023 at 4:06 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern.
No further information was provided prior to exit.
Mar 2022
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, facility document review and clinical record review, it was determined that two of 50 residents in the survey sample were not invited to their care plan m...
Read full inspector narrative →
Based on resident interview, staff interview, facility document review and clinical record review, it was determined that two of 50 residents in the survey sample were not invited to their care plan meetings/conference, Resident #50 and Resident #93.
The findings include:
1. Resident #50 (R50) was not invited to their care plan meeting/conference.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/15/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indication the resident is not cognitively impaired for making daily decisions.
An interview was conducted with R50 on 3/28/22 at 11:17 a.m. When asked if she attended her care plan meetings, a gathering when the facility staff discuss the care of plan for the resident, R50 stated they were not aware of any meetings like this. When asked if R50 was invited to the meetings, R50 stated no, they were not.
Review of the clinical record on 3/28/2022, failed to evidence documentation related to R50 being invited to their care plan meeting/conference.
On 3/29/2022 at 1:50 p.m. a request was made to ASM (administrative staff member) #1, the administrator, for documentation of inviting R50 to her care plan meeting/conference.
On 3/29/2022 at 4:15 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation of the resident's invitation to their care plan meeting.
An interview was conducted with ASM #2, the interim director of nursing and the MDS coordinator, on 3/29/2022 at 4:19 p.m. ASM #2. When asked the process for inviting residents to their care plan meeting, ASM #2 stated it was based on the MDS schedule. ASM #2 stated the social worker goes to the family and resident to determine a time and asks the family if they would like to participate, and they should ask the resident at that time and go over the time with them. When asked if it was documented that the resident have been invited, ASM #2 stated the social worker can answer that question.
An interview was conducted with OSM (other staff member) #5, the social worker, on 3/29/2022 at 4:28 p.m. When asked the process for inviting the residents to their care plan meetings, OSM #5 stated she calls the emergency contact, or whomever is listed on the profile. OSM #5 stated she talks to the resident as to whom she should call. When asked how she invites the resident to the care plan meeting, OSM #5 stated she lets them know when it is and whom to invite. When asked if she documents that she has invited the resident, OSM #5 stated, no. When asked if she invited [R50] to her care plan, OSM #5 stated she had not participated in a care plan with [R50] as she had just started at the facility in January.
The facility policy, Interdisciplinary Care Conference documented in part, The patient, patient representative and family are invited to attend and participate in the care conference.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
2. Resident #93 (R93) was not invited to their care plan meeting/conference.
On the most recent MDS assessment, a quarterly assessment, with an ARD of 3/17/2022, the resident scored a 7 out of 15 on the BIMS score, indicating the resident is severely cognitively impaired for making daily decisions.
An interview was conducted with R93 on 3/28/2022 at 11:02 a.m. When asked if they attended the care plan meetings, R93 stated they did not know anything about any meetings. When asked if they were invited to the care plan meetings, R93 stated no.
Review of the clinical record on 3/28/2022 failed to evidence any documentation related to R93 being invited to their care plan meeting/conference.
On 3/29/2022 at 1:50 p.m. a request was made to ASM (administrative staff member) #1, the administrator, for documentation of inviting R50 to her care plan meeting/conference.
On 3/29/2022 at 4:15 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation of the resident's invitation to their care plan meeting.
An interview was with ASM #2, the interim director of nursing and the MDS coordinator, on 3/29/2022 at 4:19 p.m. ASM #2. When asked the process for inviting residents to their care plan meeting, ASM #2 stated it was based on the MDS schedule. ASM #2 stated the social worker goes to the family and resident to determine a time and asks the family if they would like to participate, and they should ask the resident at that time and go over the time with them. When asked if it was documented that the resident have been invited, ASM #2 stated the social worker can answer that question.
An interview was conducted with OSM (other staff member) #5, the social worker, on 3/29/2022 at 4:28 p.m. When asked the process for inviting the residents to their care plan meetings, OSM #5 stated she calls the emergency contact, or whomever is listed on the profile. OSM #5 stated she talks to the resident as to whom she should call. When asked how she invites the resident to the care plan meeting, OSM #5 stated she lets them know when it is and whom to invite. When asked if she documents that she has invited the resident, OSM #5 stated, no. When asked if she invited [R93] to their care plan, OSM #5 stated the facility staff just had a care plan meeting for them and their son came. When asked if she invited the resident, OSM #5 stated, no.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to promote dignity for one of 50 residents in th...
Read full inspector narrative →
Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to promote dignity for one of 50 residents in the survey sample, Resident #43 (R43). Resident #43 was observed with visible dandruff flakes and crusty patches on the scalp, a noticeable body odor, dry and cracked areas on the lips with visible film in the corners of the mouth and white filmy substance on the fold area under their neck during an incontinence care observation on 3/29/2022.
The findings include:
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/31/2022, the resident was assessed as being severely impaired for making daily decisions. Section G of the assessment documented R43 as being totally dependent on one staff member for dressing, eating, toileting and personal hygiene. The MDS assessment further documented R43 being always incontinent of bowel and bladder and receiving tube feeding.
On 3/29/2022 at 10:23 a.m., an observation was made of TNA (temporary nursing assistant) #10 providing ADL (activities of daily living) care to R43. TNA #10 prepared a basin of warm water with a washcloth and towel and began washing R43's face. When asked about the dandruff flakes and crusty patches on the scalp, TNA #10 explained that R43 had cradle cap really bad. When asked if R43's hair was washed, TNA #10 stated that they did not shampoo R43's hair because they were not trained how to do this. When asked if R43's hair was washed on shower days, TNA #10 stated that they did not take R43 to the shower because they were not trained how to use the shower chair or shower stretcher. TNA #10 stated that they knew that R43's family wanted R43 to have showers because they had been told this but they could only do what they were trained to do. TNA #10 stated that R43 was very contracted and they did not want to hurt them so they did the best they could with R43. TNA #10 proceeded to wash under R43's chin and cleaned a filmy substance off of the area. An area on the right side of the neck and lower right jaw had small red raised bumps on it. TNA #10 stated that R43 had a rash on that area and they were afraid to wash the area too hard so it would not bleed. Body odor was smelled when TNA #10 washed R43's armpit areas through masks worn during care. TNA #10 began to provide incontinence care and apply a new gown to R43. When asked about R43's mouth care and dry lips, TNA #10 stated that they should use mouth swabs to provide mouth care for R43 but they were never trained how to use them and they did not want to hurt R43. TNA #10 stated that they put Vaseline on R43's lips at times that they got from R43's roommate. TNA #10 stated that these observations were from lack of care and that they were only able to get so much of R43 clean with the training they had received but they did the best that they could do for R43.
The comprehensive care plan dated 2/19/2021 documented in part, ADL Self care deficit. Date Initiated: 02/19/2021 .Assist to bathe/shower as needed .Assist with daily hygiene, grooming, dressing, oral care and eating as needed.
On 3/29/2022 at 12:24 p.m., an observation of R43 was made with ASM (administrative staff member) #2, the interim director of nursing/MDS coordinator. ASM #2 observed R43's visible dandruff flakes and crusty patches on the scalp and dry and cracked areas on the lips with film in corners of the mouth. ASM #2 was made aware of the body odor and substance on the fold area under the neck during ADL care on 3/29/2022 and stated that dignity was not being promoted. ASM #2 was made aware that showers, hair washing and mouth care were not being done due to lack of training and stated that they needed to review what training the TNA's were receiving for ADL care.
The facility policy, Focus on FTag557 documented in part, .Respect and Dignity. The resident has a right to be treated with respect and dignity .
The facility policy, Resident Rights documented in part, .The resident has a right to a dignified existence, self-determination, and communication with an access to persons and services outside the facility. 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 .
On 3/29/2022 at 4:41 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant and ASM #5, the former administrator were made aware of the above concern.
No further information was provided prior to exit.
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 resident interview 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 50 residents in the...
Read full inspector narrative →
Based on resident interview 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 50 residents in the survey sample, Resident #47. The facility staff failed to honor Resident #47's (R47) preference for night time snacks in bed.
The findings include:
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/11/22, 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. R47's comprehensive care plan dated 2/7/22 documented, Honor food preferences . A physician's order for speech-language pathology dated 3/25/22 documented, Patient to be OOB (out of bed) for all regular textured meals.
On 3/28/22 at 3:17 p.m., an interview was conducted with R47. R47 stated requests for snacks at night time have been verbalized but the staff will not provide snacks. R47 stated a couple of weeks ago, the speech therapist recommended the resident be seated in a wheelchair for meals and the staff have not been assisting the resident out of bed for breakfast. R47 stated a nurse said the resident could not eat meals in bed so the resident could not have snacks in bed at night.
On 3/29/22 at 6:42 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated R47 has asked for snacks while in bed at night time, and she asked the nurse who stated, No.
On 3/29/22 at 7:05 a.m., an interview was conducted with CNA #3. CNA #3 stated she used to give R47 snacks while in bed at night time, but stopped because of a choking hazard and the therapy staff said they did not want R47 to eat in bed. CNA #3 stated R47 reported other staff was providing snacks while the resident was in bed so she spoke with a nurse who said she confirmed with the therapy staff that R47 could have snacks while in bed.
On 3/29/22 at 7:44 a.m., an interview was conducted with OSM (other staff member) #3 (the speech therapist). OSM #3 stated she recommended R47 eat all textured meals out of bed for safety because of the meat included in the meals. OSM #3 stated R47's snacks consist of chips and crackers and it is safe for the resident to eat these snacks while sitting up in bed. OSM #3 stated LPN (licensed practical nurse) #4 told her R47 always requests snacks while in bed and LPN #4 thought if R47 could not have meals in bed then it was not safe for the resident to eat snacks in bed. OSM #3 stated last week, she explained to LPN #4 that the way she wrote the order was for R47 to be up for three regular textured meals a day and it is safe for the resident to eat snacks in bed as long as the resident is positioned upright in bed.
On 3/30/22 at 7:19 a.m., an interview was conducted with LPN #4. LPN #4 stated approximately three weeks ago, the speech therapist said R47 had to be up in the chair for each meal. LPN #4 stated the evening nurse told her to not worry about giving R47 snacks during the night shift because the resident eats a lot of snacks while in the chair during the evening shift. When asked if R47 was receiving snacks during the night shift, LPN #4 stated it was not made clear to her until last Friday or Saturday that R47 could eat snacks in the bed. LPN #4 stated R47 requested snacks during the night shift and she told the resident he had to be up in the chair to eat. LPN #4 stated R47 was not assisted to the chair to eat a snack.
On 3/29/22 at 3:38 p.m., an interview was conducted with LPN #2. LPN #2 stated she would honor a resident's preference for snacks in bed even if she thought this was not safe, as long as the resident was cognitively intact and was sitting up in bed.
On 3/29/22 at 4:42 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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...
Read full inspector narrative →
**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 the notice of the right to appeal discharge from Medicare Part A services for 1 of 50 residents in the survey sample; Resident #200.
The findings include:
Resident #200 was admitted on [DATE] and discharged on 2/1/22. Resident #200 was receiving skilled services that ended on 1/26/22. The resident was not provided with an Advance Beneficiary Notice (ABN) which document a resident's right to appeal the decision to discontinue skilled services.
On the most recent MDS (Minimum Data Set), an Admission/5-Day assessment, with an ARD (Assessment Reference Date) of 1/12/22, Resident #200 was unable to complete the resident portion of the BIMS (Brief Interview for Mental Status exam) interview and was coded as being moderately impaired in ability to make daily life decisions on the staff interview regarding the resident's cognition.
A review of the facility document, Notice of Medicare Non-Coverage (NOMNC) was reviewed. This form documented, Your Medicare provided and/or health plan have determined that Medicare probably will not pay for your current Skilled Nursing and Skilled Rehabilitation services after the effective date indicated above. You may have to pay for any services you receive after the above date. Your Right to Appeal This Decision: You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal .
A review of the physical therapy discharge note dated 1/26/22 documented, Patient has made consistent progress with skilled interventions and Patient has reached maximum potential with skilled services. Patient is supposed to be discharged to home with family to assist and home health services to follow up on safety and mobility.
On 3/30/22 at approximately 10:00 AM, the NOMNC was requested from ASM #1 (Administrative Staff Member) the Administrator, for Resident #200. On 3/30/22 at 10:41 AM, ASM #1 was unable to provide a NOMNC for Resident #200, stating that one was not provided because the resident had left the facility of their own choice prior to completing therapy. Information was requested regarding any documentation that reflected this discharge status, showing that an NOMNC was not required.
On 3/30/22 at 11:20 AM, ASM #1 returned with therapy notes, as documented above, and stated that the last covered day was 1/26/22 and that the resident converted to private pay and remained in facility for 5 additional days under private pay until the spouse chose to take Resident #200 home. He stated that an NOMNC should have been issued when Resident #200 converted to private pay.
No further information was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to prevent neglect for one of 50 residents in th...
Read full inspector narrative →
Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to prevent neglect for one of 50 residents in the survey sample, Resident #43 (R43). Resident #43 was observed with visible dandruff flakes and crusty patches on the scalp, a noticeable body odor, dry and cracked areas on the lips with visible film in the corners of the mouth and white filmy substance on the fold area under their neck during an incontinence care observation on 3/29/2022.
The findings include:
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/31/2022, the resident was assessed as being severely impaired for making daily decisions. Section G of the assessment documented R43 as being totally dependent on one staff member for dressing, eating, toileting and personal hygiene. The MDS assessment further documented R43 being always incontinent of bowel and bladder and receiving tube feeding.
On 3/29/2022 at 10:15 a.m., a request was made to TNA (temporary nursing assistant) #10 to observe incontinence care for R43.
On 3/29/2022 at 10:23 a.m., an observation was made of TNA #10 providing ADL (activities of daily living) care to R43. TNA #10 prepared a basin of warm water with a washcloth and towel and begam to wash R43's face. When asked about the dandruff flakes and crusty patches on the scalp, TNA #10 explained that R43 had cradle cap really bad. When asked if R43's hair was washed, TNA #10 stated that they did not shampoo R43's hair because they were not trained how to do this. When asked if R43's hair was washed on shower days, TNA #10 stated that they did not take R43 to the shower because they were not trained how to use the shower chair or shower stretcher. TNA #10 stated that they knew that R43's family wanted them to have showers because they had been told this, but they could only do what they were trained to do. TNA #10 stated that R43 was very contracted and they did not want to hurt them so they did the best they could. TNA #10 washed under R43's chin and cleaned a white filmy substance off of the area. An area on the right side of the neck and lower right jaw was observed to have small red raised bumps on it. TNA #10 stated that R43 had a rash on that area and they were afraid to wash the area too hard so it would not bleed. Body odor was smelled when TNA #10 washed R43's armpit areas through masks worn during care. TNA #10 proceeded to provide incontinence care and apply a new gown to R43. When asked about R43's mouth care and dry lips, TNA #10 stated that they should use mouth swabs to provide mouth care for R43 but they were never trained how to use them and they did not want to hurt R43. TNA #10 stated that they put Vaseline on R43's lips at times that they got from R43's roommate. TNA #10 stated that these observations were from lack of care and that they were only able to get so much of R43 clean with the training they had received, but they did the best that they could do for R43.
The comprehensive care plan dated 2/19/2021 documented in part, ADL Self care deficit. Date Initiated: 02/19/2021 .Assist to bathe/shower as needed .Assist with daily hygiene, grooming, dressing, oral care and eating as needed.
On 3/29/2022 at 12:24 p.m., an observation of R43 was made with ASM (administrative staff member) #2, the interim director of nursing/MDS coordinator. ASM #2 observed R43's visible dandruff flakes and crusty patches on the scalp and dry and cracked areas on the lips with film in corners of the mouth. ASM #2 was made aware of the body odor and substance on the fold area under the neck during ADL care on 3/29/2022. ASM #2 was made aware that showers, hair washing and mouth care were not being done due to lack of training and stated that they needed to review what training the TNA's were receiving for ADL care.
The facility policy, Patient Protection, Abuse, Neglect, Mistreatment and Misappropriation Prevention documented in part, .Neglect is the failure of the facility, its employees or service providers to provide goods and service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .
On 3/29/2022 at 4:41 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant and ASM #5, the former administrator were made aware of the above concern.
No further information was provided 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 and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 50 residents in the survey sample, Resident...
Read full inspector narrative →
Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 50 residents in the survey sample, Resident #51. The facility staff failed to complete the BIMS (brief interview for mental status) assessment for Resident #51's (R51) quarterly MDS assessment with an ARD (assessment reference date) of 2/16/2022.
The findings include:
Section B of R51's quarterly MDS assessment with an ARD of 2/16/2022 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 3/29/2022 at 8:00 a.m., an interview was conducted with ASM (administrative staff member) #2, interim director of nursing/MDS coordinator. ASM #2 stated that BIMS assessment was completed by social services, and if it was not completed by the ARD that dashes were entered in the area that were not completed. ASM #2 reviewed R51's quarterly MDS with the ARD of 2/16/2022 and stated that the BIMS should have been completed. ASM #2 stated that they followed the RAI (resident assessment instrument) manual in completion of the MDS assessments.
On 3/29/2022 at 2:32 p.m., an interview was conducted with OSM (other staff member) #5, social services. OSM #5 stated that they had a list of residents due for the BIMS assessment that they used to determine when they were due. OSM #5 reviewed R51's quarterly MDS with the ARD of 2/16/2022 and stated that the BIMS was not completed and should have been completed. OSM #5 stated that they did not know why the assessment was not completed.
The CMS (centers for Medicaid and Medicare services) 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) .
On 3/29/2022 at 4:41 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant and ASM #5, the former administrator were made aware of the above concern.
No further information was presented 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
Based on observations, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory therapy in a sanitary manner for o...
Read full inspector narrative →
Based on observations, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory therapy in a sanitary manner for one of 50 residents in the survey sample, Resident #59. The facility failed to store Resident #59's oxygen equipment in a sanitary manner.
The findings include:
Resident #59's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status score), indicating the resident was not cognitively impaired. The resident was coded as requiring limited assistance in bed mobility, dressing, toileting, bathing and personal hygiene; supervision with transfers/locomotion and independence in eating.
Resident #59 was observed with the nasal cannula oxygen tubing lying on the bed and the nebulizer face mask lying face down on bedside table on 3/28/22 at 9:00 AM, 3:55 PM and 3/29/22 at 12:15 PM.
Resident #59's care plan dated 4/23/21 with no revision date, revealed the following, Focus: At risk for respiratory impairment related to congestive heart failure. Interventions: Administer oxygen/medications/treatments per physician order.
A review of the physician's orders dated 3/17/21, revealed the following, Oxygen at 2 liters nasal cannula for shortness of breath as needed. Albuterol nebulizer 2.5 milligram/3 milliliters vial nebulizer every 6 hours as needed for shortness of breath.
An interview was conducted on 3/28/22 at 9:00 AM with Resident #59. When asked if they use the oxygen, Resident #59 stated they use it every night and if they need it in the day. When asked if they removes the oxygen herself, Resident #59 stated they take it off themselves. When asked if they turn the oxygen off, Resident #59 stated, No, my roommate shuts it off.
An interview was conducted on 3/29/22 at 12:20 PM with ASM (administrative staff member) #2, the interim director of nursing. When asked how the oxygen tubing and nebulizer mask should be stored when not in use, ASM #2 stated it should be stored in a plastic bag. ASM #2 asked Resident #59 if they use oxygen. Resident #59 stated they use it every night. ASM #2 stated would bring a new nebulizer mask and oxygen tubing to the resident.
An interview was conducted on 3/29/22 at 2:19 PM with LPN (licensed practical nurse) #3. When asked the proper care and storage for respiratory therapy supplies, LPN #3 stated when the supplies are not in use, they go into a plastic bag to protect it.
On 3/29/22 at 4:40 PM, ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
According to the facility's Oxygen Administration policy dated 7/17, revealed the following, Equipment: plastic bag for oxygen cannula or mask storage.
According to the facility's Respiratory: Nebulizer Mist Therapy policy dated 9/14, revealed the following, Equipment: labeled and dated plastic bag for nebulizer and mouthpiece of mask storage.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review and clinical record review, it was determined one of 50 residents in the survey sample received unnecessary psychotropic medications, Resident #6 (R6...
Read full inspector narrative →
Based on staff interview, facility document review and clinical record review, it was determined one of 50 residents in the survey sample received unnecessary psychotropic medications, Resident #6 (R6). For Resident #6, the facility staff failed to ensure a proper diagnosis for the use of Seroquel (Quetiapine Fumarate) (used to treat schizophrenia, Bipolar disorder and in addition to other medications to treat depression) (1); and failed to identify target behaviors for the Seroquel.
The findings include:
On the most recent MDS assessment, a quarterly assessment, with an ARD of 12/31/2021, the resident was coded as having both short and long term memory problems and was severely impaired to make daily decisions. In Section N - Medications, R6 was coded as receiving seven days of an antipsychotic during the look back period.
The physician orders dated, 2/28/2022, documented, Quetiapine Fumarate Tablet 25 MG (milligrams), give 50 MG via G-Tube (gastrostomy tube - a tube placed through the abdomen into the stomach for feeding) (2), two times a day for antipsychotic.
The physician order dated, 3/9/2022, documented, Seroquel Tablet 50 MG, give 50 MG via G - tube two times a day for anxiety.
The physician order dated, 3/25/2022 documented, Quetiapine Fumarate tablet 25 MG; give 25 MG via G- tube in the morning related to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side until 4/2/2022.
The physician order dated, 3/25/2022 documented, Seroquel 50 MG tablet, give 50 MG via G - tube at bedtime related to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side until 4/2/2022.
Review of the March 2022 MAR (medication administration record) revealed the above medications administered as ordered.
The comprehensive care plan dated, 10/7/2021, documented in part, Focus: At risk for adverse effects related to: use of antipsychotic medication .Administer medications as ordered. Notify physician of decline in ADL (activities of daily living) ability or mood/behavior related to a dosage change. Report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors, etc.
Review of the nurse's notes for March, February and January 2022 failed to evidence any documentation of any behaviors for R6.
An interview was conducted with LPN (licensed practical nurse) #1 on 3/29/2022 at 2:40 p.m. When asked what Seroquel is given for, LPN 31 stated it depends on the patient, but it can be given for depression. When asked if a diagnosis of hemiplegia and hemiparalysis be an appropriate diagnosis for the use of Seroquel, LPN #1 stated no. When asked what R6's targeted behaviors were, LPN #1 stated they can be aggressive. When asked where she documents the behaviors for R6, LPN #1 stated she has not had to document any as he hasn't had any while she was on duty. LPN #1 stated some residents have a check box on the MAR for behaviors. LPN #1 stated she would need to check further.
On 3/29/2022 at 3:05 p.m., LPN #1 stated she had clarified the order for Seroquel with the hospice nurse and the diagnosis is psychosis. When asked where the behaviors are documented, LPN #1 stated the facility charts by exception and would only chart if the resident has behaviors.
An interview was conducted with ASM (administrative staff member) #3, the quality assurance consultant) on 3/29/2022 at 3:12 p.m. When asked what Seroquel is used for, ASM #3 stated it's used to treat psychosis, and is an antipsychotic. When asked if it is used for hemiplegia or hemiparalysis, ASM #3 stated not that she was aware of. When asked if the facility should have a targeted behavior of the use of an antipsychotic, ASM #3 stated the behavior would be psychosis. When asked where behaviors are monitored, ASM #3 stated they should be documented in the progress notes if the resident is having an episode. ASM #3 stated if there is no documentation of behaviors in the progress notes, then it is perceived the resident did not have any behaviors. The physician order above was reviewed with ASM #3. ASM #3 stated the order needs to be clarified, and that those are not proper diagnoses for the use of the Seroquel.
The facility policy, Behavior Management Guidelines documented in part, The use of psychoactive medications should be utilized only as long as is necessary as demonstrated by the patient's behavior Non-pharmacological interventions should be attempted prior to the use of any psychoactive medication .The individualized comprehensive care plan addresses the behavior management program, the goal for behavior management, individualized interventions to address the patient's specific risk factors and the plan for reductions of risk related to behaviors .In the event a patient experiences a new or escalating behaviors; behaviors are documented in [initials of computer program].
ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, and ASM #5, the former administrator, were made aware of the above concern on 3/30/2022 at approximately 8:45 a.m.
No further information was obtained prior to exit.
REFERENCES
(1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a698019.html
(2) This information was obtained from the following website: https://medlineplus.gov/ency/article/002937.htm
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
3. The facility staff failed to provide a well maintained comfortable environment for Resident #36 (R36). A hole was observed in R36's bathroom door.
On the most recent MDS (minimum data set), a quart...
Read full inspector narrative →
3. The facility staff failed to provide a well maintained comfortable environment for Resident #36 (R36). A hole was observed in R36's bathroom door.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/22/2022, 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.
On 3/28/2022 at 11:50 a.m., an observation was made of R36's room. The door to R36's bathroom had a hole in the door approximately two inches long by five inches wide. The area was observed to expose the sheetrock beneath the exterior door. At this time an interview was conducted with R36. R36 stated that a CNA (certified nursing assistant) had accidentally hit the door with the hoyer lift (mechanical patient lift equipment) back in November or December causing the hole, and the area had been there since then. R36 stated that they did not use the restroom because they were bedbound but would like the area fixed. R36 stated that no one had been in to look at the area since it happened.
Additional observations on 3/28/2022 at 9:45 a.m. and 3/29/2022 at 10:15 a.m. revealed the findings as described above.
On 3/28/2022 at 12:45 p.m., an interview was conducted with OSM (other staff member) #4, the director of maintenance at sister facility. OSM #4 stated that they came over twice a week because there was no maintenance director currently. OSM #4 stated that monthly room rounds were conducted in the facility. OSM #4 stated that they used the TELS (The Equipment Lifecycle System) for maintenance work orders entered by staff. OSM #4 stated that they would check to see if there were any work orders in place for R36's bathroom door. OSM #4 observed R36's bathroom door and stated that they would be able to get the repairs done.
On 3/29/2022 at 1:25 p.m., OSM #4 stated that there were no work orders in place for R36's bathroom door.
On 3/29/2022 at 2:12 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they called maintenance directly if there were any issues that needed repairs. LPN #5 stated that they had never entered a workorder into the computer and always called or either spoke with maintenance staff face to face on the unit.
On 3/29/2022 at 4:41 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant and ASM #5, the former administrator were made aware of the above concern.
No further information was presented prior to exit.
Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide a sanitary environment for three of 50 residents in the survey sample, Residents #97, #36, and #47.
The findings include:
1. For Resident #97, the facility staff failed to clean the window tracks and behind the toilet in the resident's bathroom, creating an unsanitary environment.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/21/22, Resident #97 (R97) was coded as scoring 15 out of 15 on the BIMS (brief interview for mental status), indicating she had no cognitive impairment for making daily decisions.
On 3/27/22 at 2:06 p.m., R97 was observed lying in bed. R97 was awake and alert. R97 directed attention to the areas in the window tracks and behind the toilet in the bathroom The window tracks contained dried, black material that was not easily scraped with a fingernail. The area behind and around the toilet contained a dark brownish-black stain about 6 inches in width and 3 inches in length. R97 stated housekeepers are in and out of the room quickly, and the perception is that no one takes the time needed to notice or clean thoroughly.
On 3/28/22 at 10:47 a.m., OSM (other staff member) #1, environmental services director, was interviewed. When asked what is included in cleaning a resident's room, she stated some tasks are completed daily: dumping trash, wiping down all surfaces, cleaning bathrooms, and mopping. She stated other tasks are considered to be deep cleaning, and occur once weekly on a set schedule: air conditioning units, windows, detailing bathrooms, furniture. OSM #1 was asked to observe the cleanliness conditions of R97's room as detailed above. OSM #1 stated the area under the bureau did not appear to have been dusted in some time, the window tracks had not been cleaned as they should, and the bathroom should have been caught way before now. She stated the room was not at an acceptable standard for cleanliness. When asked who follows up to make sure housekeepers are cleaning as they should, she stated she should be following up, but if there is a call out, she has to cover for her staff and she does not have time to go behind housekeepers to monitor their performance. She stated R97's room location is problematic, because there is not one particular housekeeper assigned to clean the room consistently. When asked if she would describe the window tracks and area around the toilet as sanitary, she stated she would not.
On 3/28/22 at 11:20 a.m., ASM (administrative staff member) #1, the administrator, observed R97's room for cleanliness. After looking at the window and the area behind the toilet, he stated there are concerns with the cleanliness of the room.
On 3/28/22 at 11:37 a.m., ASM #1, ASM #3, the quality assurance consultant, ASM #4, the regional director of operations, and ASM #5, the former administrator, were informed of these concerns.
A review of the facility's housekeeping daily work assignment sheets and daily deep cleaning schedules revealed tasks and schedules which verified the information provided by OSM #1's interview.
No further information was provided prior to exit.
2. The facility staff failed to maintain a functioning toilet in Resident #47's (R47) room.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/11/22, 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.
On 3/28/22 at 3:17 p.m., an interview was conducted with R47. R47 stated the toilet in the room has been broken for the past month and won't flush. R47 stated this was verbalized to someone in the maintenance department but the toilet has not been fixed. R47 stated they did not use the toilet but the staff used the toilet to empty urine from the resident's urinary catheter bag. At this time, an observation of the toilet was conducted. There was toilet paper in the toilet and the toilet did not flush after the handle was pushed.
On 3/29/22 at 7:20 a.m., another observation of the toilet was conducted. There was no toilet paper in the toilet and the toilet did not flush after the handle was pushed.
On 3/29/22 at 9:54 a.m., an interview was conducted with OSM (other staff member) #4 (the maintenance director for a sister facility). OSM #4 stated the facility currently did not employ maintenance staff but someone from his facility comes to this facility twice a week. OSM #4 stated toilets are inspected on a monthly basis but other staff can enter a work order into the computerized work order system if repairs are needed. OSM #4 stated he was not aware that R47's toilet was not functioning until this morning but R47 may have reported the broken toilet to another maintenance employee that comes over from the sister facility.
On 3/30/22 at 10:32 a.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated the CNAs go into resident bathrooms every day and most of the time, residents report if a toilet isn't working. CNA #4 stated the nursing staff can submit a maintenance slip if a toilet is not functioning.
On 3/29/22 at 4:42 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern.
No further information was presented prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
5. The facility staff failed to place Resident #43's (R43) call light in a position where they could access it.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessme...
Read full inspector narrative →
5. The facility staff failed to place Resident #43's (R43) call light in a position where they could access it.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/31/2022, the resident was assessed as being severely impaired for making daily decisions. Section G coded R43 being totally dependent on one person for dressing, eating, toileting and personal hygiene. Section G further documented R43 having impairment in both upper extremities.
On 3/27/2022 at 12:30 p.m., R43 was observed lying in bed with the call bell located in the nightstand drawer beside the bed. R43 was unable to verbalize when asked about the call bell.
Additional observations on 3/27/2022 at 2:45 p.m., 3/28/2022 at 8:34 a.m. and 3/28/2022 at 4:39 p.m. revealed the findings above.
On 3/29/2022 at 2:12 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that call bells were placed within the residents reach whether they were able to use the bell or not. LPN #5 stated that all residents need a way to call for help regardless of their level of cognition. LPN #5 stated that they had never seen R43 use the call light but they always made sure it was near their hand and accessible to them. LPN #5 stated that call bell placement should be checked every time anyone enters the resident's room and at least every shift. LPN #5 was made aware of the observations of R43's call bell on 3/27/2022 and 3/28/2022 and stated that the nursing assistants may have placed it in the drawer while providing care and forgotten to put it back in place.
On 3/29/2022 at 4:41 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were made aware of the findings.
No further information was presented prior to exit.
6. The facility staff failed to place Resident #29's (R29) call light in a position where they could access it.
On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/19/2022, the resident scored a 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired for making daily decisions. Section G coded R29 requiring extensive assistance of one person for dressing, toileting and personal hygiene. Section G further documented R29 having no impairment in the upper extremities.
The comprehensive care plan for R29 documented in part, Falls due to decreased mobility. Date Initiated: 10/27/2017. Under interventions it documented in part, .Reinforce need to call for assistance .
On 3/27/2022 at 12:36 p.m., R29 was observed in bed eating lunch, and the call bell was observed to be clipped to the sheet at the top of the mattress with the end of the call button located on the floor beside the nightstand.
Additional observations on 3/27/2022 at 2:00 p.m. revealed the same as above. On 3/28/2022 at 8:35 a.m., the call bell was observed to be clipped to the sheet of the bed at the top of the mattress with the end of the call button located over the top of the mattress behind the residents head.
On 3/29/2022 at 2:12 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that call bells were placed within the resident's reach whether they were able to use the bell or not. LPN #5 stated that all residents need a way to call for help regardless of their level of cognition. LPN #5 stated that R29 was able to use their call bell and had a history of throwing it in the floor. LPN #5 stated that they checked it often because of this. LPN #5 stated that call bell placement should be checked every time anyone enters the resident's room and at least every shift. LPN #5 was made aware of the observations of R29's call bell on 3/27/2022 and 3/28/2022 and stated that it should have been accessible to the resident.
On 3/29/2022 at 4:41 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were made aware of the findings.
No further information was presented prior to exit.
7. Facility staff failed to provide Resident # 58 (R58) access to their personal clothing.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/19/2022, 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 G Functional Status coded R58 as being independent with Locomotion on the unit - how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair. Under Mobility Devices R58 was coded as using a wheelchair.
On 03/29/22 at approximately 8:36 a.m., an interview was conducted with R58. R58 stated that they were unable to access their clothes in their wardrobe. When asked how they access their clothes if they want to change them R58 stated that they have to call an aide and wait until they come to the room. During the interview, R58 demonstrated their attempts to reach the wardrobe on the other side of the room without success. With R58's permission, an observation of the inside of the wardrobe revealed it was full with R58's tops, pants and other personal items.
An observation of R58's room revealed their bed was positioned in the middle of the second half of the room (B-side), the wardrobe between the outside wall and bed, approximately three and a-half feet between the foot of the bed and the wall. Further observations revealed two boxes of R58's additional clothing, were stacked at the far left corner of the room, near the foot of the bed, and a four drawer chest positioned to the left of the foot of the bed, against the wall.
Observations during the days of the survey revealed R58 propelling themselves in their wheelchair in and out of their room and throughout the unit.
On 03/29/2022 at approximately 10:15 a.m., an interview was conducted with CNA (certified nursing assistant) # 4. When asked if a resident should be able to independently access their personal items within their room, CNA # 4 stated that it is their home and they (residents) should have access to everything. After observing R58's room CNA # 4 stated that R58 could not access their wardrobe.
On 03/29/2022 at approximately 3:25 p.m., an interview and observation of R58's room was conducted with ASM (administrative staff member) # 3, quality assurance consultant. When asked if a resident should have access to their personal belongings in their room, ASM# 3 stated that the resident should have access to all of their belongings. After observing R58's room, ASM # 3 was asked if R58 had access to their wardrobe by use of their wheelchair. ASM # 3 stated there was not enough room around the foot of the bed to reach the wardrobe on the opposite side.
The facility's policy Virginia Patient/Resident [NAME] of Rights & Responsibilities documented in part, You have the right to: 14. Retain and use your personal clothing and possessions as space permits unless to do so would infringe upon rights of other patients and unless medically contraindicated as documented by your physician, physician assistant, or nurse practitioner in your medical record.
On 03/29/2022 at approximately 4:40 p.m., ASM # 1, administrator, ASM # 2, interim director of nursing, ASM # 3, quality assurance consultant and ASM # 5, former administrator, were made aware of the above findings.
No further information was provided prior to exit.
Based on observation, resident interview, staff interview, facility document review, it was determined the facility staff failed to accommodate the needs of seven of 50 residents in the survey sample, Residents #86, #50, #60, #6, #43, #29, and #58.
The finding include:
1. The facility staff failed to place Resident #86 (R86)'s call bell within their reach.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 3/16/2022, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions.
An observation was made of R86 on 3/28/2023 at 2:02 p.m. R86 was lying in bed. The call bell was in the wheelchair, next to the bed, but behind the resident's reach.
A second observation was made of R86 on 3/29/2022 a.m. R86 was lying in bed. The call bell was on the floor behind the wheelchair, not within the resident's reach.
An interview was conducted with CNA (certified nursing assistant) #4 on 3/29/2022 at 10:29 a.m. When asked where the call bells are to be placed, CNA #4 stated the call bell should be in the reach of the resident. CNA #4 stated the facility had clamps and the staff can clamp them to the sheets. CNA #4 further stated the call bells should be placed where the resident can reach it.
The facility policy, Call Light documented in part, 6. Always position call light conveniently for use and within reach. A clip may be used to secure the light.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
2. The facility staff failed to place Resident #50 (R50)'s call bell within the resident's reach.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/15/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions.
An interview was conducted with R50 on 3/28/2022 at 1:29 p.m. The call bell was observed to be hanging on the wall behind the night stand. When asked if they put it there, R50 stated, no, the staff put it there.
A second observation was made of R50's room on 3/29/2022 at 8:45 a.m. The call bell was again observed hanging on the wall behind the night stand.
An interview was conducted with CNA (certified nursing assistant) #4 on 3/29/2022 at 10:29 a.m. When asked where the call bells are to be placed, CNA #4 stated the call bell should be in the reach of the resident. CNA #4 stated the facility had clamps and the staff can clamp them to the sheets. CNA #4 further stated the call bells should be placed where the resident can reach it.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
3. The facility staff failed to place Resident #60 (R60)'s call bell within the resident's reach.
On the most recent MDS assessment, a quarterly assessment, with an ARD of 3/3/2022, the resident scored a 10 out of 15 on the BIMS, indicating the resident was moderately cognitively impaired for making daily decisions.
Observation was made of R60 on 3/28/2022 at approximately 10:30 a.m. R60 was in the bed, asleep. The call bell was on the floor to R60's right side of the bed.
A second observation was made on 3/29/2022 at 8:41 a.m. R60 was sitting up in the bed with their breakfast tray in front of them. The call bell was on the floor to R60's right side of the bed.
An interview was conducted with CNA (certified nursing assistant) #4 on 3/29/2022 at 10:29 a.m. When asked where the call bells are to be placed, CNA #4 stated the call bell should be in the reach of the resident. CNA #4 stated the facility had clamps and the staff can clamp them to the sheets. CNA #4 further stated the call bells should be placed where the resident can reach it.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
4. The facility staff failed to place Resident # 6 (R6)'s call bell within the resident's reach.
On the most recent MDS assessment, a quarterly assessment, with an ARD of 12/31/2021, the resident was coded as having both short and long term memory problems, and was severely impaired to make daily decisions.
Observation was made of 3/28/2022 at 10:24 a.m. R6 was in the bed. The call bell was on the floor under the bed. Observations were made on 3/28/2022 at 11:36 a.m., 1:49 p.m. and 3:38 p.m., the call bell remained on the floor under the bed.
An interview was conducted with CNA (certified nursing assistant) #4 on 3/29/2022 at 10:29 a.m. When asked where the call bells are to be placed, CNA #4 stated the call bell should be in the reach of the resident. CNA #4 stated the facility had clamps and the staff can clamp them to the sheets. CNA #4 further stated the call bells should be placed where the resident can reach it.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
7. The facility staff failed to maintain a clean and homelike environment for Resident #452. During the initial resident interview on 3/27/22 at 3:30 PM, a two foot square of wallpaper was missing fro...
Read full inspector narrative →
7. The facility staff failed to maintain a clean and homelike environment for Resident #452. During the initial resident interview on 3/27/22 at 3:30 PM, a two foot square of wallpaper was missing from behind Resident #452's bed.
Resident #452's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/7/22, coded the resident as scoring 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of Resident #452's comprehensive care plan dated 2/1/19, revealed the following, FOCUS: Hoarding belongings in room and bathroom- have a safe and clean living area. INTERVENTIONS: Monitor room as needed.
An interview was conducted on 3/29/22 at 9:50 AM with OSM (other staff member) #4, the maintenance director for a sister facility. When asked his responsibilities in covering this facility, OSM #4 stated, they come over twice a week. When asked the process for environmental rounds, OSM #4 stated, they do monthly room rounds, bathroom, light switches, plugs, window fixtures, television, and resident room. When asked what work is completed, OSM #4 stated they touch up paint if needed, fix the wallpaper-ongoing issues with wallpaper in the building due to humidity. When asked how work orders are obtained, OSM #4 stated they use TELS (the equipment life safety system). The nurse or CNA (certified nursing assistant) puts in a work order, and if they can, they do the work themselves. If not, they reach out to a contractor. OSM #4 stated the wallpaper is old, and they attempt to find something that can be glued on to make the repair. He stated he was not sure why there would be just dry wall behind Resident #452's bed.
On 3/29/22 at 1:25 PM, OSM #4 stated none of the requests were in TELS, but they have been corrected now.
An interview was conducted on 3/29/22 at 2:50 PM, with LPN (licensed practical nurse) #3. When asked if missing wallpaper created a clean, homelike environment, LPN #3 stated, No that is not homelike.
On 3/29/22 at 4:40 PM, ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
No further information was provided prior to exit.
6. The facility staff failed to provide a homelike environment for Resident #87 (R87). An area with scrapes and exposed drywall was observed behind the head of R87's bed.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/16/2022, 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.
On 3/27/2022 at 12:18 p.m., an observation was made of R87's room. The area behind R87's head of bed was observed to be scraped with areas of exposed drywall and peeling paint. At this time an interview was conducted with R87. R87 stated that the area on the wall was from the trapeze bar on the bed hitting the wall. R87 stated that they had requested the facility to put a protective board on the wall but no one had been in to fix the area or look at it. R87 stated that the area had been there over four months now, and they wanted the staff to fix the area when they were out of bed one day because they did not want to have to move to another room.
Additional observations on 3/28/2022 at 9:30 a.m. and 3/29/2022 at 11:12 a.m. revealed the findings as described above.
On 3/29/2022 at 12:45 p.m., an interview was conducted with OSM (other staff member) #4, the director of maintenance at a sister facility. OSM #4 stated that they came over twice a week because there was no maintenance director currently. OSM #4 stated that monthly room rounds were conducted in the facility. OSM #4 stated that they used the TELS (The Equipment Lifecycle System) for maintenance work orders entered by staff. OSM #4 stated that they would check to see if there were any work orders in place for R87's wall behind the bed. OSM #4 observed R87's wall behind the bed and stated that they would be able to get the repairs done. OSM #4 discussed the repairs with R87 and stated that they would not have to move to another room to have this completed, as it would not take the whole day.
On 3/29/2022 at 1:25 p.m., OSM #4 stated that there were no work orders in place for R87's wall behind the head of the bed.
On 3/29/2022 at 2:12 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they called maintenance directly if there were any issues that needed repairs. LPN #5 stated that they had never entered a work order into the computer and always called or either spoke with maintenance staff face to face on the unit.
On 3/29/2022 at 4:41 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant and ASM #5, the former administrator were made aware of the above concern.
No further information was presented prior to exit.
Complaint deficiency
Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide a clean, home-like environment for seven of 50 residents in the survey sample, Residents #97, #86, #50, #60, #6, #87, and #452 .
The findings include:
1. The facility staff failed to clean the window tracks, under the furniture, and behind the toilet in the resident's room. Additionally, the facility failed to maintain the resident's bureau in a manner free of multiple scratches and gouges, failed to repair peeling wallpaper, and failed to repair a hole in the bathroom wall.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/21/22, Resident #97 (R97) was coded as scoring 15 out of 15 on the BIMS (brief interview for mental status), indicating she had no cognitive impairment for making daily decisions.
On 3/27/22 at 2:06 p.m., R97 was observed lying in bed. R97 was awake and alert. R97 directed attention to the areas under the bureau, in the window tracks, behind the toilet, on the bedroom wall where wallpaper was peeling (behind the television table), and to a fist-size hole in the bathroom wall. R97 also directed attention to the bureau, which contained numerous chips, scrapes, and gouges in the finish. The window tracks contained dried, black material that was not easily scraped with a fingernail. The area behind and around the toilet contained a dark brownish-black stain about 6 inches in width and 3 inches in length. R97 stated housekeepers are in and out of the room quickly, and the perception is that no one takes the time needed to notice or clean or repair items that need attention. R97 stated: I am ashamed to invite my grandchildren to visit me here because of the condition of this place. R97 stated they feel like none of the staff members cares about the residents' living conditions.
On 3/28/22 at 10:47 a.m., OSM (other staff member) #1, environmental services director, was interviewed. When asked what is included in cleaning a resident's room, she stated some tasks are completed daily: dumping trash, wiping down all surfaces, cleaning bathrooms, and mopping. She stated other tasks are considered to be deep cleaning, and occur once weekly on a set schedule: air conditioning units, windows, detailing bathrooms, furniture. OSM #1 was asked to observe the cleanliness conditions of R97's room as detailed above. OSM #1 stated the area under the bureau did not appear to have been dusted in some time, the window tracks had not been cleaned as they should, and the bathroom should have been caught way before now. She stated the room was not at an acceptable standard for cleanliness. When asked who follows up to make sure housekeepers are cleaning as they should, she stated she should be following up, but if there is a call out, she has to cover for her staff and she does not have time to go behind housekeepers to monitor their performance. She stated R97's room location is problematic, because there is not one particular housekeeper assigned to clean the room consistently. When asked if she would describe R97's room as homelike, she stated she absolutely would not. When asked if environmental services staff should have noticed the gouges in the bureau, the peeling wallpaper, and the holes in the wall, she stated they should have noticed all these things and reported them to her.
On 3/28/22 at 11:20 a.m., ASM (administrative staff member) #1, the administrator, observed R97's room for cleanliness and for being homelike. After looking at the window, gouges in the bureau, peeling wallpaper, hole in the bathroom wall, and condition of the area behind and around the toilet, he stated there are concerns with the room, and that the room was not homelike.
On 3/28/22 at 11:37 a.m., ASM #1, ASM #3, the quality assurance consultant, ASM #4, the regional director of operations, and ASM #5, the former administrator, were informed of these concerns.
A review of the facility policy, Focus on F Tag 584, revealed, in part: The resident has a right to a safe, clean, comfortable, and homelike environment .The facility must provide .housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .A determination of 'homelike' should include the resident's opinion of the living environment.
No further information was provided prior to exit.
2. The facility staff failed to maintain a homelike environment for Resident #86 (R86). The wallpaper behind the bed was torn and ripped.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 3/16/2022, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions.
Observation was made on 3/28/2022 at 2:02 p.m. of R86's room. The wall behind the bed had torn and ripped wallpaper. A second observation was made on 3/29/2022 at 8:47 a.m. The wall behind the bed had torn and ripped wallpaper.
On 3/29/2022 at 9:50 a.m. an interview was conducted with OSM (other staff member) #4, the maintenance director at a sister facility. When asked how they are made aware of any maintenance repairs that are needed, OSM #4 stated they come over twice a week and make complete what needs to be done. OSM #4 stated the previous maintenance director was terminated a week ago. When asked the process for maintaining the facility, OSM #4 stated they make monthly room rounds where they check the bathrooms, light switches, plugs, window fixtures, TV, no screws sticking out and touch up paint if need. OSM #4 stated the wallpaper is an ongoing issue in the building due to humidity. OSM #4 stated they use [name of computer program to put in maintenance requests]. They (CNAs [certified nursing assistants]/nurses) put in a work order, if maintenance can do it, they do it and if not, they reach out to a contractor. OSM #4 stated the wallpaper is old, try to find a glue on and try to put that up. OSM #4 stated that the requests from [name of computer program] come across on their phones. On 3/29/2022 at 1:25 p.m. OSM #4 stated the wallpaper behind R86's room was not in [name of computer program].
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
3. The facility staff failed to maintain a homelike environment for Resident #50 (R50). The wallpaper behind the bed was torn and ripped.
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/15/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indication the resident is not cognitively impaired for making daily decisions.
Observation was made of R50's room on 3/28/2022 at 11:17 a.m. The wallpaper behind the resident's bed was ripped and torn. An interview was conducted with R50 on 3/28/22 at 11:17 a.m. When asked how long the wallpaper has been that way, R50 stated it had been that way since they were moved to this room.
On 3/29/2022 at 9:50 a.m. an interview was conducted with OSM (other staff member) #4, the maintenance director at a sister facility. When asked how they are made aware of any maintenance repairs that are needed, OSM #4 stated they come over twice a week and make complete what needs to be done. OSM #4 stated the previous maintenance director was terminated a week ago. When asked the process for maintaining the facility, OSM #4 stated they make monthly room rounds where they check the bathrooms, light switches, plugs, window fixtures, TV, no screws sticking out and touch up paint if need OSM #4 stated the wallpaper is an ongoing issue in the building due to humidity. OSM #4 stated they use [name of computer program to put in maintenance requests]. They (CNA [certified nursing assistants]/nurses) put in a work order, if we can do we do it and if not we reach out to a contractor. OSM #4 stated the wallpaper is old, we try to find a glue on and try to put that up. OSM #4 stated if we give me the room number, he will look up in [name of computer program]. OSM #4 stated that the requests from [name of computer program] comes across on their phones. On 3/29/2022 at 1:25 p.m. OSM #4 stated the wallpaper behind R50's room was not in [name of computer program].
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
4. The facility staff failed to maintain a homelike environment for Resident #60 (R60). The privacy curtain had a brown substance on it.
On the most recent MDS assessment, a quarterly assessment, with an ARD of 3/3/2022, the resident scored a 10 out of 15 on the BIMS, indicating the resident was moderately cognitively impaired for making daily decisions.
Observation was made of R60's room on 3/28/2022 at 10:30 a.m. and 3:39 p.m. The privacy curtain was partially pulled around the bed to approximately the level of the resident's waist. The resident was asleep.
A second observation was made on 3/29/2022 at 8:41 a.m. R60 was in the bed, sitting up and eating breakfast. The brown substance was still on the privacy curtain.
An interview was conducted with OSM #1, the environmental services director, on 3/29/2022 at 10:54 a.m. When asked how often the privacy curtains are checked for stains or changed, OSM #1 stated the staff should be looking at them when they are cleaning the room, and let us know if there is any soil on them. When asked if she was made aware of R60's privacy curtain, OSM #1 stated she was aware of it two weeks ago and it was changed. The above observation was shared with OSM #1. OSM #1 returned at 11:27 a.m. and stated the curtain looked like it was coffee and pudding. When asked if that was a homelike environment, OSM #1 stated, no.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
5. The facility staff failed to maintain a homelike environment for Resident #6 (R6). There was a milky substance on the lower half of the closet door.
On the most recent MDS assessment, a quarterly assessment, with an ARD of 12/31/2021, the resident was coded as having both short and long term memory problems and was severely impaired to make daily decisions. In Section K - Nutritional Status, R6 was coded as receiving their nutrition by a feeding tube.
Observation was made of R6's room on 3/28/2022 at 10:24 a.m. and 1:49 p.m. The closet door, next to the resident's bed, had a splattering of a milky substance on the lower half of the door. R6's tube feeding was not running at the time. A third observation was made on 3/28/2022 at 3:38 p.m. The closet door still had the milky substance on the lower half of the door and the R6's tube feeding was infusing.
On 3/29/2022 at 8:40 a.m. an observation was made of R6's room. The tube feeding was infusing and the milky substance on the lower half of the closet door was still there.
An interview was conducted with OSM #1, the environmental services director, on 3/29/2022 at 10:54 a.m. When asked how often does the furniture get cleaned or wiped down, OSM #1 stated furniture should be wiped down every Friday. OSM #1 stated if there is something they see in between, then they are to clean it. The above observation was shared with OSM #1. OSM #1 returned at 11:27 a.m. and stated the substance on the closet door was not syrup but whatever was spilled on the door, when she wiped it, it came right off. OSM #1 stated she did not know what it was. When asked if that is homelike to have that on the furniture, OSM #1 stated it was not.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
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 provide evidence that all required information was provided to the hospita...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 50 residents in the survey sample were transferred to the hospital, Residents #452, #66, #67, #6, and #93.
1. The findings include:
The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #452 was transferred to the hospital on 3/20/22. Per the facility's Acute Care Documentation Checklist, the following documents should be sent to the receiving hospital when a resident is transferred there from the facility: INTERACT (interventions to reduce acute care transfers) care form, advanced directives, physician orders, facility's Transfer/Discharge Record, and the comprehensive care plan goals. No evidence of these documents being provided was revealed.
Resident #452's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/7/22, coded the resident as scoring 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the nursing progress note dated 3/20/22 at 7:04 PM, revealed the following, CNA (certified nursing assistant) notified nurse at 5:00 P.M. of the aforementioned resident complaining of chest pain and SOB (shortness of breath). Vitals blood pressure-154/86, pulse-70, respirations-22, temperature-97.8, oxygen saturation-95% on room air. Resident appeared to be in respiratory distress. 911 assistance requested. Emergency assistance arrived and transported resident to hospital. RP (responsible party) and NP (nurse practitioner) notified.
On 3/28/22 at approximately 5:00 PM a request was made for the evidence the required information was provided to the hospital on 3/20/22 for Resident #452.
On 3/29/22 at approximately 9:00 AM, the nursing progress note dated 3/20/22 at 7:04 PM was provided.
ASM (administrative staff member) #3, the quality assurance consultant, stated, We do not have any additional evidence of the transfer to hospital for this resident.
An interview was conducted on 3/29/22 at 3:32 PM, with LPN (licensed practical nurse) #2. When asked what documents are provided when a resident is transferred to the hospital, LPN #2 stated they provide the acute care transfer form, relevant laboratory results, face sheet and medication list. She stated they call report to the receiving facility. She stated they don't send the care plan. She stated there is a big envelope in which to put all of these. When asked how they evidence what has been sent with the resident to the hospital, LPN #2 stated they usually make a copy of the one sheet and put it in the chart. The acute care transfer is usually in the chart. She stated if it is an emergency 911 call, all the documents are not sent.
On 3/29/22 at 4:40 PM, ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
According to the facility's Interdisciplinary Care Transitions Checklists policy, dated 10/19, which reveals, Assess patient for change in condition. Notify physician of change in condition and obtain new orders. Initiate new orders. Complete 'Acute Care Transfer Documentation Checklist'. Collect necessary documents including a 'Transfer/Discharge Record' and copy of the patient's comprehensive care plan goals from medical record and place in envelope. Seal envelope. Remove top copy and place in the patient's clinical record.
No further information was provided prior to exit.
2. The facility staff failed to evidence the required documentation was provided to the receiving facility for a facility initiated transfer for Resident #66 (R66) on 2/22/2022.
On the most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 3/5/2022, the resident scored a 15 out of 15 indicating the resident is not cognitively impaired for making daily decisions.
The nurse's note dated 2/22/2022 documented in part, [Name of nephrologist] from [initials of hospital] called facility and stated that resident needs to be sent to [initials of hospital] ER (emergency room) due to creatinine of 10.5, hemoglobin 6.2 and K (potassium) 6.5. States that resident needs to get dialysis right away and he wants him (sic) taken to [initial of hospital]. Called MD (medical doctor) and received order to send resident to ER per Nephrologist request. RP (responsible party) was called and ambulance called. Writer also called [initials of hospital] to assure that resident would be accepted since hospital was on Ambulance diversional, spoke with MD at ER that will accept resident to ER.
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence of the medication list, care plan and other clinical documents were sent with R66 at the time of their transfer on 2/22/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation related to the documents sent with R66 upon transfer to the hospital on 2/22/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked the process for sending a resident out to the hospital, LPN #2 stated on evening shift we assess them, call MD (medical doctor), family. We fill in an acute care transfer form. We send relative labs, face sheet and med (medication) list. The nurse calls report. When asked if they send the care plan goals with the resident, LPN #2 stated no, we don't send the care plan. When asked if there is a way to evidence that these items were sent with the resident, LPN #2 stated there is a form to check off what has been sent with the resident, there is a big envelope. When asked, how do you evidence what has been sent, LPN #2 stated, they usually make a copy of the one sheet and put it in the chart. LPN #2 stated the acute care transfer is usually in the chart. She further stated, sometimes you don't get all that information for a 911 call.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
3. The facility staff failed to evidence the required documentation was provided to the receiving facility for a facility initiated transfer for Resident #67 (R67) on 3/19/2022.
On the most recent MDS assessment, with an ARD of 3/7/2022, the resident scored a 7 out of 15 on the BIMS score, indicating the resident was severely cognitively impaired to make daily decisions.
The nurse's note dated, 3/19/2022 at 7:04 p.m. documented, Resident bs (blood sugar) reading high. Resident refused insulin coverage. RP (responsible party) spoke with resident to encourage insulin coverage via FaceTime and resident still refused. NP (nurse practitioner) called and new order obtained to send to ER (emergency room) for eval (evaluation), RP aware. Ambulance called for transport to [name of hospital].
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence of the medication list, care plan and other clinical documents were sent with R66 at the time of their transfer on 3/19/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation related to the documents sent with R67 upon transfer to the hospital on 3/19/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked the process for sending a resident out to the hospital, LPN #2 stated on evening shift we assess them, call MD (medical doctor), family. We fill in an acute care transfer form. We send relative labs, face sheet and med (medication) list. The nurse calls report. When asked if they send the care plan goals with the resident, LPN #2 stated no, we don't send the care plan. When asked if there is a way to evidence that these items were sent with the resident, LPN #2 stated there is a form to check off what has been sent with the resident, there is a big envelope. When asked, how do you evidence what has been sent, LPN #2 stated, they usually make a copy of the one sheet and put it in the chart. LPN #2 stated the acute care transfer is usually in the chart. She further stated, sometimes you don't get all that information for a 911 call.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
4. The facility staff failed to evidence the required documentation was provided to the receiving facility for a facility initiated transfer for Resident #6 on 2/24/2022.
On the most recent MDS assessment, a quarterly assessment, with an ARD of 12/31/2021, the resident was coded as having both short and long term memory problems and was severely impaired to make daily decisions.
The nurse's note dated, 2/24/2022 at 7:35 a.m. documented in part, Went to resident room at 6:00 a.m. to give him his medication and found peg tube on the floor, not bleeding noted from site, call placed to doctor on call. [Name of person on call] received order to send to [Name of hospital], hospice also called and informed of above. Called (sic) placed to person on contact list, informed of what had happen and was told resident was going to be sent out to the hospital to have peg tube replaced. Vital signs stable. Call placed to ambulance. 7:35 (a.m.) ambulance here to pick up resident.
A request was made on 3/29/2022 at 1:50 p.m. of ASM (administrative staff member) #1, the administrator, for evidence of the medication list, care plan and other clinical documents were sent with R6 at the time of their transfer on 2/24/2022.
On 3/29/2022 at 4:03 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation related to the documents sent with R6 upon transfer to the hospital on 2/24/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked the process for sending a resident out to the hospital, LPN #2 stated on evening shift we assess them, call MD (medical doctor), family. We fill in an acute care transfer form. We send relative labs, face sheet and med (medication) list. The nurse calls report. When asked if they send the care plan goals with the resident, LPN #2 stated no, we don't send the care plan. When asked if there is a way to evidence that these items were sent with the resident, LPN #2 stated there is a form to check off what has been sent with the resident, there is a big envelope. When asked, how do you evidence what has been sent, LPN #2 stated, they usually make a copy of the one sheet and put it in the chart. LPN #2 stated the acute care transfer is usually in the chart. She further stated, sometimes you don't get all that information for a 911 call.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
5. The facility staff failed to evidence the required documentation was provided to the receiving facility for a facility initiated transfer for Resident #93 (R93) on 1/15/2022.
On the most recent MDS assessment, a quarterly assessment, with an ARD of 3/17/2022, the resident scored a 7 out of 15 on the BIMS score, indicating the resident is severely cognitively impaired for making daily decisions.
The nurse's note dated, 1/15/2022 documented, Resident noted with low O2 (oxygen) saturation 81 - 86%. Initiated O2 at 2 l/m (liters per minute). MD on all notified. Gave order to give O2 at 2 l/m and to increase PRN (as needed). Also to give call back to on-call if O2 needs increased. Write check O2 sat (saturation) on 2l/m O2 at 94% with deep breaths. Resident was repositioned in bed. Rechecked O2 sat 2 hours later noted O2 sat down to 86% on 2l/m, increased O2 to 2 l/m called MD on call to inform. MD on call gave order to send to [initials of hospital] ER due to desaturation at this time. EMT (emergency medical technician) called for transport. Report given to EMT. MD on call informed of transfer. Resident is own RP and was made aware of transport to [initials of hospital]. Transfer sheet sent with EMT.
A request was made on 3/28/2022 at 4:51 p.m. of ASM (administrative staff member) #1, the administrator, for evidence of the medication list, care plan and other clinical documents were sent with R93 at the time of their transfer on 1/15/2022.
On 3/29/2022 at 8:10 a.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation related to the documents sent with R93 upon transfer to the hospital on 1/15/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked the process for sending a resident out to the hospital, LPN #2 stated on evening shift we assess them, call MD (medical doctor), family. We fill in an acute care transfer form. We send relative labs, face sheet and med (medication) list. The nurse calls report. When asked if they send the care plan goals with the resident, LPN #2 stated no, we don't send the care plan. When asked if there is a way to evidence that these items were sent with the resident, LPN #2 stated there is a form to check off what has been sent with the resident, there is a big envelope. When asked, how do you evidence what has been sent, LPN #2 stated, they usually make a copy of the one sheet and put it in the chart. LPN #2 stated the acute care transfer is usually in the chart. She further stated, sometimes you don't get all that information for a 911 call.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
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 written documentation to the Resident and/or RP (responsible part...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident and/or RP (responsible party) and ombudsman upon a facility initiated transfer for five out of 50 residents in the survey sample, Residents #452, #66, #67, #6, and #93.
1. The findings include:
The facility staff failed to evidence written documentation to the Resident/RP and Ombudsman when Resident #452 was transferred to the hospital on 3/20/22.
Resident #452's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/7/22, coded the resident as scoring 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired.
A review of the nursing progress note dated 3/20/22 at 7:04 PM, revealed the following, CNA (certified nursing assistant) notified nurse at 5:00 P.M. of the aforementioned resident complaining of chest pain and SOB (shortness of breath). Vitals blood pressure-154/86, pulse-70, respirations-22, temperature-97.8, oxygen saturation-95% on room air. Resident appeared to be in respiratory distress. 911 assistance requested. Emergency assistance arrived and transported resident to hospital. RP (responsible party) and NP (nurse practitioner) notified.
On 3/28/22 at approximately 5:00 PM a request was made for the evidence of written notification to the RP and ombudsman when Resident #452 was transferred to the hospital on 3/20/22.
On 3/29/22 at approximately 9:00 AM, the nursing progress note dated 3/20/22 at 7:04 PM was provided.
ASM (administrative staff member) #3, the quality assurance consultant, stated, We do not have any additional evidence of the transfer to hospital for this resident.: When asked if there was additional evidence of RP or ombudsman written notification, ASM #3 stated there was none.
An interview was conducted on 3/29/22 at 3:32 PM, with LPN (licensed practical nurse) #2. When asked what written notification is provided to the RP and ombudsman when a resident is transferred to the hospital, LPN #2 stated the nurses make a phone call to the RP and document in the chart. She stated she did not know if anything else is sent to the family. She stated she did not know about the ombudsman.
An interview was conducted on 3/29/22 at 4:29 PM with OSM (other staff member) #5, the social worker. When asked about the written notification to the ombudsman, OSM #5 stated she started work at the facility in January 2022, and someone was else doing the ombudsman notification. She stated she actually found out about that ombudsman notification today.
On 3/29/22 at 4:40 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
According to the facility's Interdisciplinary Care Transitions Checklists policy, dated 10/19: Transition from skilled nursing facility to acute care: notify patient, family and representative. Issue written notification per state specific guidelines; consult a representative from the legal department with questions. Notify ombudsman.
No further information was provided prior to exit.
2. The facility staff failed to provide written notification to the resident and/or responsible party for a facility initiated transfer, and failed to notify the ombudsman of a transfer to the hospital on 2/22/2022 for Resident #66 (R66).
On the most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 3/5/2022, the resident scored a 15 out of 15, indicating the resident is not cognitively impaired for making daily decisions.
The nurse's note dated 2/22/2022 documented in part, [Name of nephrologist] from [initials of hospital] called facility and stated that resident needs to be sent to [initials of hospital] ER (emergency room) due to creatinine of 10.5, hemoglobin 6.2 and K (potassium) 6.5. States that resident needs to get dialysis right away and he want him (sic) taken to [initials of hospital]. Called MD (medical doctor) and received order to send resident to ER per Nephrologist request. RP (responsible party) was called, and ambulance called. Writer also called [initials of hospital] to assure that resident would be accepted since hospital was on Ambulance diversional, spoke with MD at ER that will accept resident to ER.
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence of a written notification to the resident and/or responsible party and notification to the ombudsman for R66's transfer on 2/22/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation of a written notification to the resident and/or responsible party and did not have evidence of the ombudsman's notification of the transfer for R66 to the hospital on 2/22/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked if anything is sent or given to the resident and/or responsible party for the reason for the transfer, LPN #2 stated an affidavit is sent with the resident. When asked if the nursing staff if responsible for notifying the ombudsman, LPN #2 stated not that she knew of, and that she didn't even know how to notify the ombudsman.
An interview was conducted with OSM (other staff member) # 5, social services, on 3/29/2022 at 4:39 p.m. When asked if she notified the ombudsman of transfers to the hospital, OSM #5 stated she had just started at the facility in January 2022, and someone else was doing that. OSM #5 stated she just found out about the ombudsman notification today.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
3. The facility staff failed to provide written notification to the resident and/or responsible party for a facility initiated transfer, and failed to notify the ombudsman of a transfer to the hospital on 3/19/2022 for Resident #67 (R67).
On the most recent MDS assessment, with an ARD of 3/7/2022, R67 scored a 7 out of 15 on the BIMS score, indicating the resident was severely cognitively impaired to make daily decisions.
The nurse's note dated 3/19/2022 at 7:04 p.m. documented, Resident bs (blood sugar) reading high. Resident refused insulin coverage. RP (responsible party) spoke with resident to encourage insulin coverage via FaceTime and resident still refused. NP (nurse practitioner) called and new order obtained to send to ER (emergency room) for eval (evaluation), RP aware. Ambulance called for transport to [name of hospital].
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence of a written notification to the resident and/or responsible party and notification to the ombudsman for R67's transfer on 3/19/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation of a written notification to the resident and/or responsible party and did not have evidence of the ombudsman's notification of the transfer for R67 to the hospital on 3/19/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked if anything is sent or given to the resident and/or responsible party for the reason for the transfer, LPN #2 stated an affidavit is sent with the resident. When asked if the nursing staff if responsible for notifying the ombudsman, LPN #2 stated not that she knew of, and that she didn't even know how to notify the ombudsman.
An interview was conducted with OSM (other staff member) # 5, social services, on 3/29/2022 at 4:39 p.m. When asked if she notified the ombudsman of transfers to the hospital, OSM #5 stated she had just started at the facility in January 2022, and someone else was doing that. OSM #5 stated she just found out about the ombudsman notification today.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
4. The facility staff failed to provide written notification to the resident and/or responsible party for a facility initiated transfer, and failed to notify the ombudsman of a transfer to the hospital on 2/24/2022 for Resident #6 (R6).
On the most recent MDS assessment, a quarterly assessment, with an ARD of 12/31/2021, the resident was coded as having both short and long term memory problems and was severely impaired to make daily decisions.
The nurse's note dated 2/24/2022 at 7:35 a.m. documented in part, Went to resident room at 6:00 a.m. to give him his medication and found peg tube on the floor, no bleeding noted from site, call placed to doctor on call. [Name of person on call] received order to send to [Name of hospital], hospice also called and informed of above. Called (sic) placed to person on contact list, informed of what had happen and was told resident was going to be sent out to the hospital to have peg tube replaced. Vital signs stable. Call placed to ambulance. 7:35 (a.m.) ambulance here to pick up resident.
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence of a written notification to the resident and/or responsible party and notification to the ombudsman for R6's transfer on 2/24/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation of a written notification to the resident and/or responsible party and did not have evidence of the ombudsman's notification of the transfer for R6 to the hospital on 2/24/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked if anything is sent or given to the resident and/or responsible party for the reason for the transfer, LPN #2 stated an affidavit is sent with the resident. When asked if the nursing staff if responsible for notifying the ombudsman, LPN #2 stated not that she knew of, and that she didn't even know how to notify the ombudsman.
An interview was conducted with OSM (other staff member) # 5, social services, on 3/29/2022 at 4:39 p.m. When asked if she notified the ombudsman of transfers to the hospital, OSM #5 stated she had just started at the facility in January 2022, and someone else was doing that. OSM #5 stated she just found out about the ombudsman notification today.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
5. The facility staff failed to provide written notification to the resident and/or responsible party for a facility initiated transfer, and failed to notify the ombudsman of a transfer to the hospital on 1/15/2022 for Resident #93 (R93).
On the most recent MDS assessment, a quarterly assessment, with an ARD of 3/17/2022, the resident scored a 7 out of 15 on the BIMS, indicating the resident is severely cognitively impaired for making daily decisions.
The nurse's note dated, 1/15/2022 documented, Resident noted with low O2 (oxygen) saturation 81 - 86%. Initiated O2 at 2 l/m (liters per minute). MD on all notified. Gave order to give O2 at 2 l/m and to increase PRN (as needed). Also to give call back to on-call if O2 needs increased. Write check O2 sat (saturation) on 2l/m O2 at 94% with deep breaths. Resident was repositioned in bed. Rechecked O2 sat 2 hours later noted O2 sat down to 86% on 2l/m, increased O2 to 2 l/m called MD on call to inform. MD on call gave order to send to [initials of hospital] ER due to desaturation at this time. EMT (emergency medical technician) called for transport. Report given to EMT. MD on call informed of transfer. Resident is own RP and was made aware of transport to [initials of hospital]. Transfer sheet sent with EMT.
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence of a written notification to the resident and/or responsible party and notification to the ombudsman for R93's transfer on 1/15/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation of a written notification to the resident and/or responsible party and did not have evidence of the ombudsman's notification of the transfer for R93 to the hospital on 3/17/2022.
An interview was conducted with LPN (licensed practical nurse) #2 on 3/29/2022 at 3:32 p.m. When asked if anything is sent or given to the resident and/or responsible party for the reason for the transfer, LPN #2 stated an affidavit is sent with the resident. When asked if the nursing staff if responsible for notifying the ombudsman, LPN #2 stated not that she knew of, and that she didn't even know how to notify the ombudsman.
An interview was conducted with OSM (other staff member) # 5, social services, on 3/29/2022 at 4:39 p.m. When asked if she notified the ombudsman of transfers to the hospital, OSM #5 stated, she had just started at the facility in January 2022, and someone else was doing that. OSM #5 stated she just found out about the ombudsman notification today.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 bed hold was provided at the time of discharge to four out of 5...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed hold was provided at the time of discharge to four out of 50 residents in the survey sample, Residents #452, #66, #67 and #93.
The findings include:
1. The facility staff failed to evidence a bed hold was provided when Resident #452 was transferred to the hospital on 3/20/22.
Resident #452's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/7/22, coded the resident as scoring 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired.
A review of the nursing progress note dated 3/20/22 at 7:04 PM, revealed the following, CNA (certified nursing assistant) notified nurse at 5:00 P.M. of the aforementioned resident complaining of chest pain and SOB (shortness of breath). Vitals blood pressure-154/86, pulse-70, respirations-22, temperature-97.8, oxygen saturation-95% on room air. Resident appeared to be in respiratory distress. 911 assistance requested. Emergency assistance arrived and transported resident to hospital. RP (responsible party) and NP (nurse practitioner) notified.
On 3/28/22 at approximately 5:00 PM a request was made for the evidence of the bed hold policy when Resident #452 was transferred to the hospital on 3/20/22.
On 3/29/22 at approximately 9:00 AM, the nursing progress note dated 3/20/22 at 7:04 PM was provided.
ASM (administrative staff member) #3, the quality assurance consultant, stated, We do not have any additional evidence of the transfer to hospital for this resident. When asked if there was additional evidence of bed hold for Resident #452, ASM #3 stated, No, there is none.
An interview was conducted on 3/29/22 at 3:32 PM, with LPN (licensed practical nurse) #2. When asked how the facility makes sure a bed hold is provided when a resident is transferred to the hospital, LPN #2 stated there is a form to check off which documents are sent, and all documents are placed in an envelope that goes with the resident to the hospital. The bed hold is sent in the paperwork part. An affidavit is sent with the resident. When asked how you evidence what has been sent, LPN #2 stated they usually make a copy of the check off sheet and put it in the chart.
On 3/29/22 at 4:40 PM, ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
According to the facility's Bed Hold Policy Before/upon Transfer policy, no date noted: Before a nursing facility transfers a resident to a hospital, the nursing facility must provide written information to the resident or resident representative that specifies, the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility.
No further information was provided prior to exit.
2. The facility staff failed to evidence that the bed hold notice was given to the resident and/or responsible party upon transfer to the hospital on 2/22/2022 for Resident # 66 (R66).
On the most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 3/5/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions.
The nurse's note dated 2/22/2022 documented in part, [Name of nephrologist] from [initials of hospital] called facility and stated that resident needs to be sent to [initials of hospital] ER (emergency room) due to creatinine of 10.5, hemoglobin 6.2 and K (potassium) 6.5. States that resident needs to get dialysis right away and he want him (sic) taken to [initials of hospital]. Called MD (medical doctor) and received order to send resident to ER per Nephrologist request. RP (responsible party) was called an ambulance called. Writer also called [initials of hospital] to assure that resident would be accepted since hospital was on Ambulance diversional, spoke with MD at ER that will accept resident to ER.
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence that the bed hold policy was given to the resident and/or responsible party for R66's transfer on 2/22/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any documentation that the bed hold policy was given to the resident and/or responsible party for R66 upon transfer to the hospital on 2/22/2022.
An interview was conducted with LPN (licensed practical nurse) # 2 on 3/29/2022 at 3:39 p.m. When asked if the bed hold notice is sent with the resident upon transfer to the hospital, LPN #2 stated the bed hold notice is sent in the envelope with the resident. When asked where that is documented, LPN #2 stated there is a big envelope that contains a check list. When asked if a copy of that check list is maintained in the clinical record, LPN #2 stated, no.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
3. The facility staff failed to evidence that the bed hold notice was given to the resident and/or responsible party upon transfer to the hospital on 3/19/2022 for Resident # 67 (R67).
On the most recent MDS assessment, with an ARD of 3/7/2022, the resident scored a 7 out of 15 on the BIMS, indicating the resident was severely cognitively impaired to make daily decisions.
The nurse's note dated 3/19/2022 at 7:04 p.m. documented, Resident bs (blood sugar) reading high. Resident refused insulin coverage. RP (responsible party) spoke with resident to encourage insulin coverage via FaceTime and resident still refused. NP (nurse practitioner) called and new order obtained to send to ER (emergency room) for eval (evaluation), RP aware. Ambulance called for transport to [name of hospital].
A request was made on 3/29/2022 at 10:45 a.m. of ASM (administrative staff member) #1, the administrator, for evidence the bed hold notice was sent with R66 at the time of their transfer on 3/19/2022.
On 3/29/2022 at 12:11 p.m. ASM #3, the quality assurance consultant, stated the facility did not have any evidence the bed hold notice was sent with R67 upon transfer to the hospital on 3/19/2022.
An interview was conducted with LPN (licensed practical nurse) # 2 on 3/29/2022 at 3:39 p.m. When asked if the bed hold notice is sent with the resident upon transfer to the hospital, LPN #2 stated the bed hold notice is sent in the envelope with the resident. When asked where that is documented, LPN #2 stated there is a big envelope that contains a check list. When asked if a copy of that check list is maintained in the clinical record, LPN #2 stated, no.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
4. The facility staff failed to evidence that the bed hold notice was given to the resident and/or responsible party upon transfer to the hospital on 1/15/2022 for Resident # 93 (R93).
On the most recent MDS assessment, a quarterly assessment, with an ARD of 3/17/2022, the resident scored a 7 out of 15 on the BIMS, indicating the resident is severely cognitively impaired for making daily decisions.
The nurse's note dated, 1/15/2022 documented, Resident noted with low O2 (oxygen) saturation 81 - 86%. Initiated O2 at 2 l/m (liters per minute). MD on all notified. Gave order to give O2 at 2 l/m and to increase PRN (as needed). Also to give call back to on-call if O2 needs increased. Write check O2 sat (saturation) on 2l/m O2 at 94% with deep breaths. Resident was repositioned in bed. Rechecked O2 sat 2 hours later noted O2 sat down to 86% on 2l/m, increased O2 to 2 l/m called MD on call to inform. MD on call gave order to send to [initials of hospital] ER due to desaturation at this time. EMT (emergency medical technician) called for transport. Report given to EMT. MD on call informed of transfer. Resident is own RP and was made aware of transport to [initials of hospital]. Transfer sheet sent with EMT.
A request was made on 3/28/2022 at 4:51 p.m. of ASM (administrative staff member) #1, the administrator, for evidence the bed hold notice was sent with R93 at the time of their transfer on 1/15/2022.
On 3/29/2022 at 8:10 a.m. ASM #3, the quality assurance consultant, stated the facility did not have any evidence the bed hold notice was sent with R93 upon transfer to the hospital on 1/15/2022.
An interview was conducted with LPN (licensed practical nurse) # 2 on 3/29/2022 at 3:39 p.m. When asked if the bed hold notice is sent with the resident upon transfer to the hospital, LPN #2 stated the bed hold notice is sent in the envelope with the resident. When asked where that is documented, LPN #2 stated there is a big envelope that contains a check list. When asked if a copy of that check list is maintained in the clinical record, LPN #2 stated, no.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to evidence that they provided adequate supervision to prevent smoking accidents for Resident #21.
...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to evidence that they provided adequate supervision to prevent smoking accidents for Resident #21.
Resident #21's most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an assessment reference date of 1/20/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. Section J-Health Conditions coded the resident as no for current tobacco use.
Resident #21 was observed smoking on 3/28/22 at 10:30 AM and again on 3/29/22 at 10:30 AM.
A review of Resident #21's comprehensive care plan dated 3/28/22, revealed the following, FOCUS-History of smoking in community current smoker. INTERVENTIONS-Complete smoking evaluation. Allow to smoke in designated area at designated smoking times.
A review of the smoking evaluation dated 3/28/22 at 11:53 AM, revealed the following, Safe smoker-capable and safe, requires no assistance to smoke. Smoking evaluation completed by ASM (administrative staff member) #2.
An interview was conducted on 3/28/22 at 11:56 AM with Resident #21. When asked if he smokes, Resident #21 stated, Yes, I smoke. When asked if he has smoked since entry into the facility, Resident #21 stated he did not because, initially, he could not get out of bed because of fractures to both legs, and he could not bear weight. When asked when he started smoking, Resident #21 stated it was early February.
On 3/29/22 at 9:40 AM, an interview was conducted with Resident #21. When asked if he remembered if a smoking evaluation had been completed, Resident #21 stated that he did, and that the lady came yesterday and talked with him.
On 3/29/22 at 10:30 AM, an interview was conducted with CNA (certified nursing assistant) #5. When asked if she normally supervised the smoking, CNA #5 stated she did not supervise it every day. When asked how long Resident #21 has been smoking, CNA #5 stated the resident had been smoking a couple of months.
On 3/29/22 at 2:40 PM, ASM #2, the interim director of nursing, was interviewed. When asked if she had completed a smoking evaluation on Resident #21 on 3/28/22, ASM #2 stated she did. When asked when she had completed the smoking evaluation, ASM #2 stated she did it yesterday. When asked why she had completed the evaluation on 3/28/22, ASM #2 stated she was told that he was smoking and needed one.
An interview was conducted on 3/29/22 at 3:20 PM with ASM #3, the quality assurance consultant. When asked what the protocol is for allowing a resident to smoke, ASM #3 stated a smoking assessment should be done. When asked how often a smoking assessment is done, ASM #3 stated that if the residents smoke on admission, if there is a change in their smoking status, if there is an overall change in their condition that might affect their ability to smoke then a smoking assessment is done. When asked if a smoking evaluation should be done when a resident started smoking, ASM #3 stated, Yes, that would have been a change in his smoking status.
On 3/29/22 at 4:40 PM, ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
No further information was provided prior to exit.
2. The facility staff failed to implement application of a smoking apron during observations of Resident #51(R51) smoking on 3/27/2022 and 3/28/2022.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/16/2022, the BIMS (brief interview for mental status) was not completed. The assessment documented R51 as being able to understand others and able to express ideas and wants. R51's most recent annual assessment with an ARD of 8/18/2021 documented current tobacco use.
On 3/27/2022 at 10:42 a.m., an observation was conducted of nine residents smoking in the designated smoking area at the facility. R51 was observed sitting in a wheelchair smoking a cigarette; no smoking apron was observed to be in place. R51s was observed with visible contractures of both hands. R51 was able to manipulate the cigarette during the observation and was observed to brush ashes off of their pants once with their hand.
An additional observation on 3/28/2022 at 10:51 a.m. revealed R51 smoking in the designated smoking area without the use of a smoking apron. R51 was observed once wiping ashes off of the pants they were wearing with their hand.
On 3/28/2022 at approximately 2:45 p.m., an interview was conducted with R51 in their room. R51 stated that they smoked four times a day in the designated smoking area, with the facility staff supervising. R51 stated that a smoking apron was used a couple of years ago but it was not necessary because R51 thought it was ridiculous.
The facility smoking evaluation dated 2/19/2020 for R51 documented in part, .Patient is free of physical limitations interfering with the ability to perform safe smoking techniques, e.g., able to grasp and handle cigarette, lighter or matches without assistance. No .Patient has arthritis and gout that affects hands is able to smoke on most days when arthritis isn't acting up, however for safety has agreed to wear smoking apron. The areas on the assessment for Safe Smoker and At risk smoker were both left blank.
R51's comprehensive care plan documented in part, History of smoking and current smoker. Date Initiated: 12/06/2019. Revision on: 02/19/2020 .Provide with a smoking apron and assist to put on .
On 3/27/2022 at 10:42 a.m., an interview was conducted with CNA (certified nursing assistant) #14. CNA #14 stated that a different aide was assigned to supervise smoking each day and they obtained the cigarettes and lighters from the nurse at the designated time. CNA #14 stated that smoking was allowed four times a day and was 15 minutes long. CNA #14 stated that the smoking box containing all cigarettes and lighters was kept in the locked medication room. CNA #14 stated that they were an agency CNA and were not aware of any residents who required any special interventions for smoking, and the nurse would let them know if anyone needed these.
On 3/29/2022 at 12:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they were not sure where the smoking aprons were kept and thought they were kept outside. LPN #3 stated that R51 used an extender for their cigarettes that was kept in the smoking box, was not aware of the use of a smoking apron.
On 3/29/2022 at 12:28 p.m., an interview was conducted with CNA #5. CNA #5 stated that the nurses let them know if a resident required a smoking apron or not. CNA #5 stated that smoking aprons were stored outside in the designated smoking area in a plastic storage box and proceeded to show where they were. CNA #5 stated that R51 has not used an apron when she was supervising smoking and had used a guard that helped them get a better grip at times. Four smoking aprons were observed to be in a plastic storage box in the designated smoking area.
On 3/29/2022 at 3:12 p.m., an interview was conducted with ASM (administrative staff member) #3, quality assurance consultant. ASM #3 stated that residents who smoke should have a smoking assessment completed. ASM #3 stated that if a smoking apron was documented to be in use on the assessment then the facility staff should be using one or the assessment should have been updated to reflect that it was not needed anymore.
The facility policy Smoking Policies documented in part, .Smoking Education for Patients and Families .As a patient in the center, your physical and cognitive function will need to be assessed by your nurse. That assessment will be reviewed by the interdisciplinary team and your attending physician who will then decide if you are a Safe or At-Risk Smoker .
On 3/30/2022 at 4:41 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance coordinator and ASM #5, the former administrator were made aware of the above concern.
No further information was provided prior to exit.
4. The facility staff failed to assist Resident #47 (R47) out of bed into a wheelchair to safely eat breakfast, per the speech therapist's recommendations.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/11/22, 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. R47's comprehensive care plan revised on 3/23/22 documented, Offer to get up into W/C (wheelchair) at end of night shift and to sit up in W/C for all meals .
A review of R47's clinical record revealed a speech therapy Discharge summary dated [DATE] that documented R47 presented with a medical history of difficulty swallowing and further documented, Compensatory Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake .Upright posture during meals and Upright posture for > (greater than) 30 mins (minutes) after meals .Collaborated with team regarding patient's discharge/transition planning . A physician's order for speech-language pathology dated 3/25/22 documented, Patient to be OOB (out of bed) for all regular textured meals.
On 3/28/22 at 3:17 p.m., an interview was conducted with R47. R47 stated that a few weeks ago, the speech therapist put on record that R47 was supposed to be out of bed in the morning to eat due to swallowing issues but the nurses and CNAs (certified nursing assistants) were giving R47, A hard time and not getting the resident out of bed for breakfast.
On 3/29/22 at 6:42 a.m., an interview was conducted with CNA (certified nursing assistant) #2 (a night shift CNA). CNA #2 stated the former director of nursing and LPN (licensed practical nurse) #4 has told her staff from the therapy department wants R47 out of bed before breakfast because the resident can't eat in bed. However, CNA #2 stated that on certain nights, LPN (licensed practical nurse) #4 tells the CNAs not to do certain tasks, depending on CNA staffing. CNA #2 stated over the previous weekend, LPN #4 instructed her to not assist R47 out of bed because of the amount of staff.
On 3/29/22 at 7:05 a.m., an interview was conducted with CNA #3 (a night shift CNA). CNA #3 stated R47 has verbalized the need to get up every morning but most of the time, there are not enough CNAs and the resident requires two staff to assist with transfers. CNA #3 stated the former director of nursing came to her one morning at 7:10 a.m. and asked why R47 was not out of bed. CNA #3 stated there was poor communication and she did not receive confirmation that R47 was supposed to be out of bed. CNA #3 stated R47 asked to get out of bed two different mornings but LPN #4 said, No. That's a lot on y'all to get him up. CNA #3 stated R47 asked how to receive assistance with getting out of bed and she told the resident to talk to the day shift staff and therapy staff because she was not certain about the resident's care plan and the resident slides in the wheelchair. CNA #3 stated LPN #4 knows R47 slides in the wheelchair and it would be difficult for a staff member to stay with R47 after the resident is assisted into the wheelchair.
On 3/29/22 at 7:44 a.m., an interview was conducted OSM (other staff member) #3 (the speech therapist). OSM #3 stated R47 was admitted on a mechanical soft diet and wanted a speech therapy evaluation for an upgrade to a regular textured diet. OSM #3 stated she developed strategies and techniques so R47 could tolerate a regular texture without a risk of aspiration, choking and coughing. OSM #3 stated she recommended R47 eat all three meals in the wheelchair because this is the safest position at a 90 degree angle for the resident to eat and safely tolerate meat. OSM #3 stated she worked with CNAs, nurses, the former unit manager, the former director of nursing and the former administrator on this strategy for the last week and a half. OSM #3 stated the nursing staff was trying to determine if the night shift staff or the day shift staff should assist R47 out of bed before breakfast. OSM #3 stated it didn't matter who assisted R47 out of bed but she did not want the resident served breakfast until the resident was out of bed for safety reasons.
On 3/29/22 at 2:45 p.m., an interview was conducted with CNA #1 (a day shift CNA who routinely cares for R47). CNA #1 stated she begins her shift at 8:00 a.m. and R47 is usually in bed when she arrives. CNA #1 stated nurses have asked her to assist R47 out of bed before she serves breakfast but the breakfast trays are already on the unit when she arrives so she asked if the night shift can assist R47 out of bed. CNA #1 stated R47 has been eating breakfast in bed most of the time.
On 3/30/22 at 7:19 a.m., an interview was conducted with LPN #4. LPN #4 stated approximately three weeks ago, the speech therapist said R47 has to be out of bed and in the chair to eat so the former director of nursing assigned the night shift staff to assist the resident out of bed. LPN #4 stated the night shift staff have been assisting R47 out of bed every morning except for one morning when there was only one CNA. LPN #4 stated she explained to R47 that she did not want the resident or the CNA to get hurt. LPN #4 stated the day shift staff arrives at 7:00 a.m. and they can assist R47 out of bed.
On 3/30/22 at 7:42 a.m., an interview was conducted with ASM (administrative staff member) #2 (the interim director of nursing). ASM #2 stated the nursing staff care planned R47 for being assisted out of bed for breakfast. ASM #2 stated R47 likes to get up before breakfast because the resident needs to sit up for meals. ASM #2 stated the decision for the night shift staff to assist R47 out of bed was made because the breakfast trays arrive to the unit shortly after the day shift staff arrives. ASM #2 stated she sees R47 multiple times a day and she has never visualized R47 sliding in the wheelchair.
On 3/29/22 at 4:42 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern.
No further information was presented prior to exit.
Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services in a manner to promote resident safety for four of 50 residents in the survey sample, Residents # 3, # 51, # 21 and # 47.
The findings include:
1. Facility staff failed to re-evaluate (R3) for smoking.
On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/30/2021, 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 J1300 Current Tobacco Use coded (R3) as using tobacco.
On 03/28/22 at approximately 10:53 a.m., during an interview with (R3), they stated they smoked at the facility during each of the designated smoking times at 10:30 a.m., 2:30 p.m., 4:30 a.m., 8:00 p.m.
On 03/28/2022 at approximately 2:45 p.m., an observation of the facility's gazebo area revealed several facility residents smoking with a staff member present. Further observation revealed (R3) sitting in their wheelchair smoking independently.
The comprehensive care plan for (R3) dated 01/06/2021 documented in part: Focus: History of smoking in community/ current smoker. Date Initiated: 01/06/2021 .Complete Smoking Evaluation per facility guidelines. Date Initiated: 01/06/2021.
The Facility's Smoking Evaluation for (R3) dated 01/06/2021 documented in part, 8. Additional Information: 8a. Comments: resident has HX (history) smoking, does not wish to smoke at this time.
Review of (R3's) clinical record failed to evidence documentation of a smoking evaluation indicating (R3) could safely smoke.
On 3/29/22 at 9:49 a.m., an interview was conducted with RN (registered nurse) # 1. RN # 1 stated that a smoking assessment was completed prior to allowing a resident to smoke to determine if it was safe for them to do so. RN # 1stated that they were not sure how often the smoking assessment was to be completed but a resident should be reassessed if they started smoking after they were assessed as non-smoking.
On 03/29/22 at approximately 3:15p.m., an interview was conducted with ASM (administrative staff member) # 3, quality assurance consultant. When asked to describe the facility's protocol for allowing a resident to smoke, ASM # 3 stated that a smoking evaluation done. When asked how often the evaluation is done ASM # 3 stated that when there is a change in a resident's smoking status or if there was an overall change in the resident's in condition. When informed of the above observation and smoking evaluation for (R3) dated 01/06/2021, ASM # 3 stated that [Name of R3] should have had another evaluation due to their desire to smoke.
The facility's policy Smoking Guidelines documented in part, Each patient who smokes will be assessed to determine if they are able to smoke safely. If you cannot smoke independently, you may be required to wear protective clothing and have assistance while smoking.
On 03/29/2022 at approximately 4:40 p.m., ASM # 1, administrator, ASM # 2, interim director of nursing, ASM # 3, quality assurance consultant and ASM # 5, former administrator, 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
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for ...
Read full inspector narrative →
Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 50 residents in the survey sample, Residents # 3 (R3). For Resident #3, the facility staff failed to conduct complete pain assessments and attempt non-pharmacological interventions prior to the administration of a prn [as needed] pain medication oxycodone-acetaminophen (1).
The findings include:
R3 was admitted to the facility with a diagnosis that included nerve pain and spinal stenosis.
On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/30/2021, 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 J0300 Pain Presence coded R3 as having frequent pain in the past 5 (five) days. Section J0600 Pain Intensity coded R3 as having a pain level of seven out of ten, with ten being the worst pain.
The physician's order for R3 documented in part, Oxycodone-Acetaminophen Tablet 5-325 MG (milligram). Give 1 tablet by mouth every 6 (six) hours as needed for pain. Order Date: 01/01/2021 Start Date: 01/01/2021.
The comprehensive care plan for R3 dated 01/04/2021 documented in part, Focus: Pain related to Spinal Stenosis, OA (osteoarthritis), neuropathy. Date Initiated: 01/04/2021 .Implement non-pharmacological interventions. Date Initiated: 01/04/2021.
The eMAR (electronic medication administration record) for R3 dated March 2022 documented the physician's order as stated above. Further review of the eMAR revealed R3 received 5-325 mgs of oxycodone-acetaminophen on the following dates and times, with no evidence of the location of pain, type of pain and non-pharmacological interventions being attempted on: 03/01/2022 at 2:02 a.m., 03/03/2022 at 3:28 a.m., 03/11/2022 at 1:43 a.m., 03/14/2022 at 4:55 a.m., 03/15/2022 at 3:30 a.m., 03/20/2022 at 6:11 a.m., and on 03/24/2022 at 9:41 p.m. Further review of the eMAR failed to evidence the location of pain and non-pharmacological interventions being attempted on: 03/22/2022 at 7:39 a.m.
On 03/28/22 at approximately 10:51 a.m., an interview was conducted with R3. When asked about pain, R3 stated there was pain in their legs. When asked what the pain felt like and how severe it was, R3 stated their legs were aching and it was a level ten from zero to ten. When asked about pain medication R3 stated they receive scheduled and prn pain medication. When asked if the staff ask about the location, intensity and type of pain, and if they try to alleviate the pain before administering the prn pain medication, R3 stated no.
On 03/29/2022 at approximately 12:50 p.m. an interview was conducted with LPN (licensed practical nurse) # 1 regarding the procedure for administering prn (as needed) pain medication and documentation of a pain assessment and non-pharmacological interventions. LPN # 2 stated the resident's pain is assessed by where the pain is allocated, thee type of pain and using a scale one to ten, with ten being the worst pain, and attempting interventions to alleviate the resident's pain before administering medication. If these are not successful, then she gives the medication. When asked about documenting the location, and type of pain and the attempts of non-pharmacological interventions LPN # 1 stated that it should be documented in the nurse's notes every time the prn pain medication if administered. After reviewing the physician's orders, the March 2022 eMAR and the nurse's progress notes dated 03/01/2022 through 03/24/2022 for R3, LPN # 2 was asked if there was documentation of the location and type of pain, and that non-pharmacological interventions were attempted prior to R3 receiving the physician ordered pain medication of oxycodone-acetaminophen on the dates listed above. LPN # 2 stated no.
The facility's policy Pain Management Guidelines documented in part, Non-pharmacologic interventions should be attempted first .
On 03/29/2022 at approximately 4:40 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, ASM # 3, quality assurance consultant and ASM # 5, former administrator, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete dialysis [1] program for two of 50 residents in the survey sample, Residents # 73 and # 66.
The findings include:
1a. The facility staff failed to provide dialysis communication forms for Resident #73's (R73's) and the dialysis center from 03/01/2022 through 03/26/2022.
Resident # 73 was admitted to the facility with diagnoses that included end stage renal disease [2].
On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/08/2022, 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 R73 for Dialysis while a resident.
The physician's order for R73 documented in part, [Name of Dialysis Center and Phone Number] chair @ (at) 9:00 (a.m.) Tues- Thurs and Sat (Tuesday, Thursday and Saturday) pick up time 8:15 a.m. scheduled transportation with [Name of Transportation Company]. Order Date: 05/18/2021.
The comprehensive care plan for R73 dated 05/20/2021 documented in part, Focus: Renal insufficiencies related to: ESRD (end stage renal disease). Date Initiated: 05/28/2021 .Days of the week: Tues, Thurs, Sat. Date Initiated: 05/28/2021.
On 03/29/2022 at approximately 8:10 a.m., ASM (administrative staff member) # 3, quality assurance consultant, provided copies the facility's dialysis communication forms for R73 dated 02/01/2022 through 02/282022. When asked about the dialysis communication forms for March 2022 ASM # 3 stated that what was provided is all that they had.
On 03/29/22 at approximately 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. When asked to describe the procedure regarding a resident's dialysis communication forms LPN # 3 stated that the nurse was responsible for completing section one of the form that included the resident's vital signs, dialysis access site, resident's status, laboratory tests, diet order, fluid restrictions, medications, sign and date the form and send it with the resident to the dialysis center. When asked how often the communication form is completed LPN # 3 stated it should be completed and sent with the resident every time they go to dialysis. When asked why it was important to complete the dialysis communication forms and send them with the resident for each dialysis visit LPN # 3 stated that it was important to make sure the resident is stable to go through the dialysis process.
On 03/29/2022 at approximately 4:40 p.m., ASM # 1, administrator, ASM # 2, interim director of nursing, ASM # 3, quality assurance consultant and ASM # 5, former administrator, were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] Dialysis treats end-stage kidney failure. It removes waste from your blood when your kidneys can no longer do their job. Hemodialysis (and other types of dialysis) does some of the job of the kidneys when they stop working well. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000707.htm.
[2] The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.
1b. The facility staff failed to monitor the bruit (1) and thrill (2) of R73's dialysis fistula according to the physician's orders.
The physician's order for R73 documented in part, Monitor/report AV (arteriovenous - relating to or affecting an artery or vein) fistula access site for s/s (signs or symptoms) of infection: redness, swelling, warmth or drainage. Every shift. Date Ordered: 06/30/2021. Start Date: 06/30/2021.
The comprehensive care plan for R73 dated 05/20/2021 documented in part, Focus: Renal insufficiencies related to: ESRD (end stage renal disease). Date Initiated: 05/28/2021. Under Interventions it documented in part Check access site for lack of thrill/bruit, evidence of infection, swelling, or excessive bleeding per facility guidelines. Report abnormalities to physician Date Initiated: 05/28/2021.
The eTAR [electronic treatment administration record] for R73 dated February 2022 documented the physician's order as stated above. Further review of the eTAR failed to evidence (R73's) bruit and thrill was checked on 02/05/2022, 02/10/2022 and 02/19/2022 on the 7:00 a.m. to 3:00 p.m. shift and on 02/09/2022 on the 3:00 p.m. to 11:00 p.m. shift.
The eTAR for R73 dated March 2022 documented the physician's order as stated above. Further review of the eTAR failed to evidence (R73's) bruit and thrill was checked on 03/13/2022, 03/20/2022, and 03/21/2022 on the 7:00 a.m. to 3:00 p.m. shift and on 03/26/2022 on the 11:00 p.m. to 7:00 a.m. shift.
On 03/29/22 at approximately 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. After reviewing the physician's or for checking (R73) bruit and thrill and the eTARs dated February and March 2022, LPN # 3 was asked if the physician's order was followed. LPN # 3 stated that if it was not documented then it wasn't done. When asked why it was important to check the bruit and thrill LPN #3 stated to ensure the access site is working properly.
On 03/29/2022 at approximately 4:40 p.m., ASM # 1, administrator, ASM # 2, interim director of nursing, ASM # 3, quality assurance consultant and ASM # 5, former administrator, were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] & [2] There are two signs that indicate a dialysis access site is functioning well. When you slide your fingertips over the site you should feel a gentle vibration, which is called a thrill. Another sign is when listening with a stethoscope a loud swishing noise will be heard called a bruit. If both of these signs are present and normal, the graft is still in good condition. This information was obtained from the website: https://www.vascularhealthclinics.org/institutes-divisions/vascular-surgery-and-medicine/dialysis-access/
2a. The facility staff failed to evidence communication with the dialysis center for seven of 13 days for Resident #66 (R66).
On the most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 3/5/2022, the resident scored a 15 out of 15 indicating the resident is not cognitively impaired for making daily decisions. In Section O - Special treatments, procedures and programs, the resident was coded as receiving dialysis while a resident at the facility.
The nurse's note dated 2/26/2022 at 6:10 p.m. documented in part, Resident is re-admit was admitted to hosp (hospital) for worsening kidney function .did have dialysis while in hospital, and to start on M - W - F (Monday - Wednesday - Friday) at [name of outpatient dialysis center), chair time is 12 .has perma (permanent) cath (catheter) to right chest and fistula to left arm.
The dialysis communication book for R66 was reviewed on 3/29/2022. There was no evidence of communication with the dialysis center for seven of the 13 days the resident went to dialysis. The missing dates were 2/28/2022, 3/2/2022, 3/4/2022, 3/16/2022, 3/18/2022, 3/21/2022, and 3/23/2022.
The comprehensive care plan dated, 10/7/2021 and revised on 2/28/2022, documented in part, Focus: Renal insufficiency related to ESRD (end stage renal disease) .Coordinate dialysis care with dialysis treatment center. Confer with physician and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis as needed.
A request was made on 3/29/2022 at 10:34 a.m. to ASM (administrative staff member) #1, the administrator, for copies of all communication forms for R66 for February and March 2022.
On 3/29/2022 at 1:26 p.m. ASM #3, the quality assurance consultant, stated the above communication forms is all the facility had.
On 03/29/2022 at approximately 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) # 3. When asked to describe the procedure regarding a resident's dialysis communication forms, LPN # 3 stated that the nurse was responsible for completing section one of the form that included the resident's vital signs, dialysis access site, resident's status, laboratory tests, diet order, fluid restrictions, medications, sign and date the form, and send it with the resident to the dialysis center. When asked how often the communication form is completed, LPN # 3 stated it should be completed and sent with the resident every time they go to dialysis. When asked why it was important to complete the dialysis communication forms and send them with the resident for each dialysis visit, LPN # 3 stated that it was important to make sure the resident is stable to go through the dialysis process.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
No further information was provided prior to exit.
2b. The facility staff failed to assess and monitor R66's dialysis access in their left arm.
The nurse's note dated, 2/26/2022 at 6:10 p.m. documented in part, Has perma cath to right chest and fistula to left arm.
Review of the physician orders failed to evidence a physician order to monitor the dialysis access sites.
The nurse's note dated, 3/11/2022 at 7:55 p.m. documented in part, Returned from dialysis .right chest dialysis catheter intact.
The nurse's note dated 3/25/2022 at 5:33 p.m. documented in part, Body audit: AV (arterial vascular) fistula left arm, dialysis cath (catheter) right chest. There was no other evidence documented that the dialysis access in the resident's left arm had been checked for a bruit and thrill.
Review of the MAR (medication administration record) and TAR (treatment administration record) for February and March 2022 revealed no documentation of checking the dialysis access in the resident's left arm for a bruit and thrill.
The comprehensive care plan dated 10/7/2021 and revised on 2/28/2022, documented in part, Focus: Renal insufficiency related to: ESRD .Check access site for lack of thrill/bruit, evidence of infection, swelling, or excessive bleeding per facility guidelines. Report abnormalities to physician.
An interview was conducted with LPN #3 0n 3/29/2022 at 2:40 p.m. When asked where R66's dialysis access is, LPN #3 stated the resident had a port in their right upper chest. When asked if R66 had any other dialysis access sites, LPN #3 stated R66 had something else but it wasn't being utilized. When asked if the resident had another access site, should that site be accessed and monitored, LPN #3 stated she would have to check on this.
On 3/29/2022 at 3; 05 p.m. LPN #3 returned and stated [R66] has a fistula in his left arm and the staff should be checking it for a bruit and thrill. When asked if she needed an order to check the bruit and thrill, LPN #3 stated, of course.
An interview was conducted with ASM #3 on 3/29/2022 at 3:12 p.m. When asked do you need a physician's order for checking a fistula for a bruit and thrill, ASM #3 stated, no. When asked why not, ASM #3 stated because it is a nursing standard of practice of care to check it. When asked how often it should be checked, ASM #3 stated at least every shift and PRN (as needed).
The facility policy, Assessment of arteriovenous shunts, fistulas & grafts documented in part, Purpose: The evaluation of arteriovenous shunts, fistulas and grafts by a licensed nurse is intended to facilitate early detection of potential complications which includes signs and symptoms of infection, leakage, and thrombosis. Any abnormal signs and symptoms should be reported to the physician .7. Observe for signs and symptoms of infection including pain, tenderness, swelling or redness around the patient's access site. 8. Place a hand over the site and palpate for the presence of thrill (motion of blood flowing through the site). 9. Using a stethoscope, auscultate over the site for the presence of bruit (a sound which may range from a whooshing noise to a whistle-like sound) .Document completion of observation or assessment on TAR. Record in Progress Note any abnormalities and subsequent interventions including communications with medical practitioner or family.
ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator, were made aware of the above concern on 3/29/2022 at 5:02 p.m.
On 3/30/2022 at 11:47 a.m. ASM #3, the quality assurance consultant, stated the facility follows their policies and procedures that are based on [NAME] as their standard of nursing practice.
No further information was provided prior to exit.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, facility document review and in the course of a complaint investigation it was determined the facility staff failed to ensure skills competencies for six of six ...
Read full inspector narrative →
Based on observation, staff interview, facility document review and in the course of a complaint investigation it was determined the facility staff failed to ensure skills competencies for six of six TNA's (temporary nursing assistants) reviewed, TNA #10, TNA #13, TNA #16, TNA #17, TNA #18, and TNA #19. For TNA #10, #13, #16, #17, #18, and #19, the facility failed to ensure each TNA possessed the skills and competencies to provide basic ADL (activities of daily living) care for residents.
The findings include:
On 3/28/2022 at 8:45 a.m., a request was made to ASM (administrative staff member) #1, the administrator and ASM #5, the former administrator for a list of all TNA's currently employed at the facility.
On 3/28/2022 at approximately 10:30 a.m., ASM #5 provided a list of 9 TNA's with their assigned unit and date of hire.
On 3/28/2022 at 12:11 p.m., a request was made to ASM #5 for evidence of training and skills competencies for TNA #13, TNA #16, TNA #17, TNA #18 and TNA #19.
On 3/29/2022 at 1:41 p.m., a request was made to OSM (other staff member) #12, human resource director for evidence of training and skills competencies for TNA #10.
On 3/29/2022 at approximately 8:00 a.m., ASM #5 provided copies of the completion certificates for AHCA/NCAL Temporary nurse aide 8 hour training online course for TNA #13, TNA #16, TNA #17, TNA #18 and TNA #19.
On 3/30/2022 at approximately 8:00 a.m., OSM #12 provided a copy of the completion certificate for AHCA/NCAL Temporary nurse aide 8 hour training online course for TNA #10.
On 3/27/2022 at 10:30 a.m., an interview was conducted with CNA (certified nursing assistant) #15. CNA #15 stated that they did not supervise or oversee the TNA's on the unit. CNA #15 stated that she had her own patient assignment and they had theirs.
On 3/27/2022 at 2:15 p.m., an interview was conducted with TNA #10. TNA #10 stated that they had been there for about 2 months. TNA #10 stated that they worked with a CNA for about 4 or 5 days for training on the floor and then were on their own. TNA #10 stated that they were told that they would be trained to become certified in February but had not been offered this yet. TNA #10 stated that at times that there were only two TNA's on the 100 unit by themselves on day shift. TNA #10 stated that they did not recall any formal skills checklist during their training and were taught what to do during the 4 or 5 days with the CNA.
On 3/29/2022 at 9:15 a.m., an interview was conducted with TNA #13. TNA #13 stated that they had been there for about 1 and a half months. TNA #10 stated that they had worked with a CNA for about 4 or 5 days shadowing them. TNA #10 stated that now the TNA's were receiving 2 days with a CNA and then were on their own with a resident assignment. TNA #10 stated that on some days there were all TNA's on the 100 unit and at times she was there with a brand new TNA alone. TNA #10 stated that she had a hard time completing her tasks for her residents because the new TNA was needing training to complete their resident assignment also. TNA #10 stated that she had previous experience in healthcare prior to this position but some of the new TNA's do not know how to use a bedpan after the 2 days of training and she has to teach them. TNA #10 stated that the facility allowed wiggle room with the staff arriving for work because they rode the bus so there were days when she was the only aide on the floor until someone else got there. TNA #10 stated that no one enforced staff arriving at 7:00 a.m. as scheduled because they were so grateful that someone showed up. TNA #10 stated that staffing had not improved since she had been working there and they were only hiring TNA's currently.
On 3/29/2022 at 10:23 a.m., an observation was made of TNA #10 providing ADL (activities of daily living) care. TNA #10 that they were not trained to use the shower stretcher or shower chair. TNA #10 stated that they were never trained how to use mouth swabs to provide mouth care. TNA #10 stated that they did the best that they could with the training they had received.
On 3/29/2022 at approximately 10:00 a.m., a request was made to ASM #3, the quality assurance consultant for any skills competencies for the TNA's selected.
On 3/29/2022 at 12:13 p.m., an interview was conducted with ASM #2, the interim director of nursing/MDS coordinator. ASM #2 stated that the TNA program was very new at the facility and they thought that TNA's required a CNA to work with them, but they had to defer to human resources.
On 3/29/2022 at 12:15 p.m., an interview was conducted with OSM #12, human resource director. OSM #12 stated that TNA's were partnered with a CNA for 2 to 3 days for training and after that they were on their own for resident care. A request was made for the procedure/policy for TNA training and skills competencies required.
On 3/29/2022 at 1:41 p.m., ASM #3 and OSM #12 stated that the skills competency for TNA's was a new process and provided a blank copy of a document titled Temporary Nurse Aide Skills Competency Checklist. OSM #12 stated that they did not have a skills competency for any of the six sampled TNA's above. OSM #12 stated that as of yesterday they realized that they did not have anything in place so they started working to catch up on these.
The facility policy Skills and Techniques Evaluation (Temporary Nurse Aide/Patient Care Assistant) dated 10/20/21 documented in part, .For each skill identified, the facilitator enters the date and skill validation or demonstration was completed and enters a full signature in the column provided. The skills and techniques evaluation is completed during job specific orientation and re-validated at least annually at the time of the employee's annual performance evaluation. To be used for new employees who complete AHCA/NCAL's Temporary Nurse Aide Training Program (www.TempNurseAide.com) .Demonstration of competency- Competency may not be demonstrated simply by documenting that staff attended a training, listened to a lecture, or watched a video. A staff's ability to use and integrate the knowledge and skills that were subject of the training, lecture or video must be evaluated by the facility staff already determined to be competent in these skill areas .
On 3/29/2022 at 4:41 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing/MDS coordinator, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were made aware of the concern.
No further information was provided prior to exit.
Complaint deficiency
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide performance evaluations and mandatory training for five of five CN...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide performance evaluations and mandatory training for five of five CNA's (certified nursing assistants) reviewed, CNAs #1, #6, #7, #8 and #9.
The findings include:
During the Sufficient and Competent Staffing facility task review on 3/29/22 at 1:38 PM revealed no evidence of performance evaluations and mandatory training for five of five CNA's (certified nursing assistants) reviewed.
On 3/28/22 at 9:40 AM, the Facility Assessment was reviewed. The facility assessment addressed the resident population, care specifics, cultural and religious factors, services provided, staff competencies, physical environment, physical structures, equipment, information systems, patient transfer agreement, and all hazard risk assessment. The facility assessment had annual review dates of 1/28/21 and 2/24/22.
On 3/29/22 at 1:38 PM, OSM (other staff member) #12, the Human Resources Director, brought in the five CNA employee records. A review of these five records revealed the following:
1. CNA #1 with a date of hire of 8/29/20, evidenced no performance evaluation, dementia training was past due.
2. CNA #6 with a date of hire of 5/9/01, evidenced dementia training past due.
3. CNA #7 with a date of hire of 1/28/08, evidenced dementia training past due.
4. CNA #8 with a date of hire of 11/23/05, evidenced dementia and abuse training past due.
5. CNA #9 with a date of hire of 11/6/17, evidenced dementia and abuse training past due.
On 3/29/22 at 1:58 PM an interview was conducted with OSM #12. When shown the results of the CNA employee file review and asked if there was a performance evaluation for CNA #1 and evidence of the mandatory education for CNA #1, #6, #7, #8 and #9, OSM #12 stated there is no evaluation for CNA #1 and the CNAs did not complete their education. She stated these are the only education sheets staff.
On 3/29/22 at 4:40 PM, ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
According to the facility's Performance Appraisals policy, dated 9/21; 'A skills techniques evaluation for all nursing assistants is to be completed annually for all nursing assistants at the time of the annual performance appraisal.
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 maintain kitchen equipment in a sanitary manner for one of one microwave, one o...
Read full inspector narrative →
Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain kitchen equipment in a sanitary manner for one of one microwave, one of one cook's refrigerators, and in one of one traditional ovens in the kitchen. On observation on 3/27/22, the microwave contained numerous pieces of food and debris, the two ovens contained grease and multiple food chunks and debris, and the cook's refrigerators contained evidence of multiple sticky liquid spills on the bottom shelf.
The findings include:
On 3/27/22 at 10:44 a.m., the kitchen was observed with OSM (other staff member) #2, the food services director. Both sides of the cook's refrigerator contained evidence of multiple liquid spills. Some of the liquid material was sticky. OSM #2 stated the refrigerator definitely needed to be wiped down. He stated the refrigerator should be cleaned each evening, and it appeared that this task was missed the previous evening. The microwave contained multiple pieces of food and debris on all four sides, the top, and the base. OSM #2 stated the microwave did not look good, and that it needed cleaning. Both sides of the traditional oven contained multiple areas of grease on the handles and exterior doors. The interior of both sides of the oven contained baked on food and greasy materials. OSM #2 stated the facility is in the process of attempting to purchase a new oven. He stated the current condition of the oven makes it impossible to get completely clean. He stated: It's not acceptable, but it's what we've been dealing with for a while. When asked if he would describe this kitchen equipment as unsanitary, he stated there was definitely room for much cleaning to be done. He stated he was not sure when a thorough cleaning of the oven had been done.
On 3/28/22 at 11:37 a.m., ASM #1, ASM #3, the quality assurance consultant, ASM #4, the regional director of operations, and ASM #5, the former administrator, were informed of these concerns.
A review of the facility policy, Ovens, revealed, in part: Cleaning Procedure .Prepare a solution according to manufacturer's guidelines of grease cutter and water in a spray bottle .Spray entire surface of the oven and allow to soak for 15 minutes .Using a brush or scrub pad, scrub all surfaces to loosen the burned-on soil. Use a dull scraper on stubborn spots .Spray or wipe outside of oven with detergent solution.
A review of the facility policy, Microwave Oven, revealed, in part: Cleaning Procedure .Wipe up spills as they occur .Wash walls inside and outside with detergent solution.
No further information was provided prior to exit.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to post daily staffing for three of four days reviewed. The facility failed t...
Read full inspector narrative →
Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to post daily staffing for three of four days reviewed. The facility failed to post daily nursing staffing on 3/27/22, 3/28/22, and 3/29/22.
The findings include:
During the Sufficient and Competent Staffing facility task review started on 3/27/22 and ending on 3/30/22, a review of the daily staffing evidenced the following:
On 3/27/22 at 10:17 AM, on the desk at the front entrance, the daily staff posting was dated 3/22/22.
On 3/28/22 at 8:00 AM, on the desk at the front entrance, the daily staff posting was dated 3/27/22.
On 3/29/22 at 10:45 AM, on the desk at the front entrance, the daily staff posting was dated 3/28/22.
On 3/29/22 at 1:10 PM an interview was conducted with OSM (other staff member) #7, the staffing coordinator. When asked who is responsible for posting the daily staffing, OSM #7 stated, I am responsible but on weekends the MOD (manager on duty) is responsible to post it. When asked if she had been on duty on 3/27/22 to post the staffing, OSM #7 stated, No, it was not me. When asked why the daily posting was not done 3/28 or 3/29, OSM #7 stated, I was doing other tasks when I came to work.
On 3/29/22 at 1:20 PM an interview was conducted with OSM #2, the food services director. When asked if he was the MOD on 3/27/22, OSM #2 stated, he was the MOD for the facility on Sunday. When asked is it your responsibility to post the staffing, OSM #2 stated, No, not that I know of. I would not know where to get this information. OSM #2 asked where this would be posted. OSM #2 stated the only thing he posts is the menu for the day.
On 3/29/22 at 4:40 PM, ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the quality assurance consultant, and ASM #5, the former administrator were informed of the above concern.
According to the facility's Posted Nurse Staffing Information policy, no date noted, which reveals, The facility must post the following information on a daily basis: Facility name, current date, total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, certified nurse aides, and resident census. The facility must post the nurse staffing data specified on a daily basis at the beginning of each shift.
No further information was provided prior to exit.
Apr 2021
22 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0658
(Tag F0658)
A resident was harmed · 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 the facility staf...
Read full inspector narrative →
**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 the facility staff failed to follow professional standards for medication administration for one of 25 residents in the survey sample, (Resident #47).
The facility staff failed to provide the care and services in accordance with professional standards of practice for documenting the administration of medications on 7/2/2020 for Resident #47. On the evening of 7/2/2020, Resident #47 was inadvertently assigned to both LPN [licensed practical nurse] #4 and RN [registered nurse] #2. LPN #4 administered the residents prescribed evening medications but failed to document the medications as administered on the eMAR [electronic medication administration record], as a result of this failure, RN #2 administered the same medications a second time to the Resident #47 a second time, resulting in a significant medication error and overdose. Resident #47 was subsequently transferred to a local hospital for evaluation/treatment. IV (intravenous) fluids, including dextrose were administered to Resident #47, in the emergency room. The resident then required admission to hospital for monitoring.
The findings include:
Resident #47 was admitted to the facility on [DATE] and transferred to the hospital on 7/2/20. Resident #47's diagnoses included but were not limited to: bipolar disorder (1), seizures (2), diabetes mellitus (3) and atherosclerosis cardiac disease (4).
Resident #47's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/15/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring limited assistance with mobility, transfers, dressing; supervision with personal hygiene and bathing and as independent in eating and locomotion. An annual assessment completed on 5/11/20 prior to the incident on 7/2/20 coded the resident as scoring a 9 out of 15 on the BIMS indicating Resident #47 was moderately impaired for cognition. Section N0350 Insulin: coded the resident as receiving insulin injections 7 out of 7 days of the look back period.
The physician orders for Resident #47 in July 2020, documented in part the following:
Medications scheduled administration time 5:00 PM:
- Losartan (anti-hypertensive) (5) 100 milligram table by mouth in the afternoon for hypertension
- Multivitamin (dietary supplement) 1 tablet by mouth in the afternoon for supplement,
- Divalproax [Depakote] (anti-epileptic) (6) 625 milligram delayed response tablet twice a day for seizure prevention,
- Metformin (anti-diabetic) (7) extended release tablet 500 milligram by mouth twice a day for diabetes mellitus,
- Olopatadine (treats allergic conjunctivitis) (8) solution 0.1% instill 1 drop in both eyes twice a day for allergies,
- Humalog Mix 75/25- inject 50 units subcutaneously twice a day before breakfast and dinner, notify MD if blood sugar less than 60 or greater than 400. Hold Humalog 75/25 if blood sugar is less than 100.
- Humalog (insulin) (9) 100 units/milliliter inject per sliding scale: if BS (blood sugar) 150-200 =4 units, BS 201-250=6 units, BS 251-300=8 units, BS 301-350=10 units, BS 351-400=12 units. If < 60 or > 350 or greater call physician, subcutaneously before meals for diabetes.
Medications scheduled administration time 9:00 PM:
- Atorvastin (anti-hyperlipidemic) (10) 10 milligram tablet by mouth at bedtime to lower cholesterol
- Cetirizine (antihistamine) (11) 5 milligram tablet at bedtime for allergies
- Gabapentin (anti-epileptic) (12) 600 milligram tablet at bedtime for nerve pain
- Melatonin (treatment for insomnia) (13) milligram tablet by mouth at bedtime for sleep
- Ziprasidone (antipsychotic) (14) 40 milligram capsule at bedtime for bipolar
- Bisoprolol (antihypertensive) (15) 10 milligram twice a day for hypertension
A FRI (facility reported incident) with an incident dated 7/2/20, and a reported date of 7/3/20, documented in part, Resident was given evening medication twice by two nurses. Resident's nurse practitioner requested the resident be sent to the hospital to be monitored due to the medication and her low blood pressure/pulse. Resident was admitted at the hospital for observation. Patient has no negative outcomes at this time. Employee action initiated or taken: Suspension/removed from schedule while investigation ongoing. Improvement plan and education initiated. If applicable date notification provided to: Responsible party: 7/3/2020, Physician: 7/3/2020, APS [adult protective services]: 7-3-2020, DHP [Department of Health Professions]: 7/3/2020
Review of the FRI investigation and follow up, documented in part, the following:
Facility investigation: Completed on: the date 7/8/2020 was handwritten on the form. An included attachment documented in part the following:
7-8-2020
FRI day 5
On 7/2/2020 it was reported that a resident was given medication twice by two different nurses. During the investigation it was found that the resident was written on two different assignment sheets, [name of LPN #4] gave the medication first, without documenting the medication in the system. [Name of RN #2] gave the medication second. The MD [medical doctor] was notified and gave an order to send the resident to the ER [emergency room]. Resident [#47] was sent to the hospital and remained there two nights under observation status. Resident [#47] returned to the facility on 7/4/2020 with no adverse reactions from the medication error and has remained stable. The DON [director of nursing] removed both nurses from the schedule while the investigation was ongoing, reconfigured the assignment sheets as well as educated the nursing staff on proper medication documentation. The investigation is complete.
Another attachment titled, Trigger Call Guideline/Agenda documented in part the following:
•
Event Type: Medication Error
•
Date and Time of Event: 7/2/20@ [at]9pm
•
Patient Name: [Name of Resident #47]
•
Cognitive Status/BIMS (date last completed): 9 as of 5/11/20
•
Timeline of Events: [Name of LPN #4] (Agency Nurse) administered the following medications to [name of Resident #47] at around 5:20pm:
•
4 units of Humalog insulin
•
Humalog Mix 75/25- 50 units
•
Metformin ER [extended release] 500 mg (milligram)
•
MVI (multivitamin)
•
Depakote 625 mg
•
Losarten Potassium 100mg
•
Bisoprolol Fumrate 10mg
•
OlapTADINE HCL (hydrochloride) eye gtts (drops)
•
[Name of LPN #5] administered the following medications around 8pm:
•
Atrovastin Calcium 10mg
•
Gabapentin 600mg
•
Melatonin 1mg
•
Ziprasidone HCL 40mg
Around 9pm [Name of RN #2] asked [Name of LPN #4] to compare assignments to make sure that no one was missed. At that time they noticed that they both had [Name of Resident #47] on their assignment sheets and they both had given her [Resident #47] her scheduled medications. They both [RN #2 and LPN#4] both went immediately to assess the resident. The resident [Resident #47] was sleeping. She [Resident #47] was easily aroused and responsive to questions. Vital signs were taken at that time. BP 95/47, 57, 16, 96% on RA [blood pressure, pulse, respirations and oxygen saturation on room air]. [Name of nurse practitioner] was notified immediately and orders were received to sent [Sic] resident to ER [emergency room]. When EMT's [emergency medical technicians] arrived resident was able to answer questions and she walked to the stretcher. EMS [emergency medical services] took her [Resident #47] blood sugar which was 146. Resident was transported to [Name of hospital]. [Name of RN #2] called report to the ER Nurse to inform her of what medications the resident [Resident #47] received in duplicate.
[Name of Resident #47's] Emergency Contact was notified of details of the incident this morning by [name of staff LPN]. DON called [Name of Resident #47's emergency contact] around 10am to explain the incident to her. During the investigation it was discovered that [Name of Resident #47] only received her Humalog 75/25 50 units once by [Name of LPN #4]. [* Note the sliding scale insulin was administered twice by both nurses for a total of 8 units of Humalog 100units/ ml].
Education has been initiated on Medication Administration to include signing off medications as you administer them to include giving medications timely as scheduled. The assignments sheets for the units were updated
The final investigation included: Statements by RN (registered nurse) #2 and LPN (licensed practical nurse) #4, both involved in the medication error event. The MAR (medication administration record) for July 2020 for Resident #47 with initials sign on code of KO9 corresponding to RN #2. The Assignment sheets for RN #2 and LPN #4.
A review of the clinical record failed to evidence any progress notes documenting the events of 7/2/20, regarding a medication error and/ or the residents transfer to the hospital.
A review of vital signs on 7/2/20 at 6:23 AM, documented in part, Blood pressure 138/65, pulse 70. Resident #47's blood sugar at 4:30 PM was documented as 179.
A review of a Discharge return anticipated MDS assessment with an assessment reference date of 7/2/20, documented in part, Unplanned transfer to acute hospital.
A review of the hospital records for Resident #47, evidenced admission to an acute care hospital on 7/2/20-7/4/20.
The emergency room record documented in part: EKG: Sinus bradycardia (low heart rate) rate of 51.
Emergency Department (ED) physician notes dated 7/2/20 11:28 PM, documented in part, She [Resident # 47] presents after getting a double dose of her medications which include extended release Metformin and Losartan. Her blood sugar dropped from 108 to 81. Her blood pressures have been on the soft side with maps (mean arterial pressures) around 65. She is getting a fluid bolus and I have ordered maintenance D5 (dextrose 5%) normal saline. Virginia Poison Control was contacted and suggests admission as Metformin was extended release and requires at least 12 hours of observation. She reports feeling sleepy, weak and somewhat confused.
The ED (emergency room) RN [registered nurse) note dated 7/2/20 at 11:00 PM documented in part, RN spoke with 'RN#2' taking care of patient from the facility. States that patient received a double dose of her evening medication. 'RN#2' states patient was given medications around 6:00 PM and again at 9:00 PM.
A review of the hospital Discharge summary dated [DATE], documented in part, Admitting diagnosis and hospital course: Accidental overdose and hypoglycemia secondary to iatrogenic [Referring to a physical or mental condition caused by a physician or healthcare provider*] insulin. Discharge Diagnosis/Plan: Accidental overdose-patient now back to baseline. EKG (electrocardiogram) x two with normal QT intervals. Diabetes Type 2-resume sliding scale insulin. Initially insulin held on admission. Hypertension-blood pressure soft due to overdose. Received IV (intravenous) fluids in ED. BP stable at this time.
LPN #4, an agency nurse, was not available for an interview and was not employed at the facility.
An interview was conducted on 4/22/21 at 4:56 PM with RN #2, the nurse supervisor. RN #2 was the second nurse who administered medications to Resident #47 on 7/2/20. When asked if she remembered the medication error on 7/2/20, RN #2 stated, Oh yes, that was the error with the agency nurse who gave medicines and didn't chart, either time. I came to give the medications to the resident [Resident #47] on my assignment sheet and since they were not signed off, I gave the 6:00 PM and 9:00 PM medications. I did not know we were both assigned to the resident until about 9:00 PM. If I had seen the medications signed off, I would have asked the other nurse about the assignment and the medications. I checked on the resident and saw that she did not look well, so I called the nurse practitioner and we transferred her to the hospital. When asked if she remembered any changes or education that were made because of the medication error, RN #2 stated, Yes, they changed the assignment sheet and the number of medication carts. We also reviewed the medication administration policy.
On 4/20/21 at 10:40 AM, during the entrance conference, when asked what standards of practice were followed, ASM (administrative staff member) #2, the director of nursing and ASM #3, the quality consultant stated, We use [NAME] and [NAME] & [NAME].
Administrative staff members (ASM) # 1, the administrator was made aware of the above concerns on 4/22/21 at 5:56 PM.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:08 AM.
According to Basic Nursing, Essentials for Practice, 6th edition ([NAME] and [NAME], 2007, pages 349-360) A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician's or health care provider's complete order on the appropriate medication form, the MAR. The MAR includes the patient's name, room, and bed number, as well as the names, dosages, frequencies, and routes of administration for each medication. When transcribing orders, ensure the names of medications, dosages, routes, and times are legible. The nurse checks all orders for accuracy and thoroughness. When orders are transcribed, the same information needs to be checked again by the nurse. It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation .Use the MAR to prepare and administer medications. When preparing medications in bottles or containers, compare the label of the medication container with the medication administration order three times: (1) before removing the container from the drawer or shelf, (2) as you remove the amount of medication ordered from the container, and (3) before returning the container to storage .After you administer medications, indicate which medications you gave on your patient's MAR per agency policy to show that you gave the medications as ordered. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about your patient's care. There are many nursing actions you take to ensure the right documentation. Make sure that the information on your patient's MAR corresponds exactly with the prescriber's order and with the label on the medication's container. Record the administration of each medication as soon as you give the medication. Never document that you have given a medication until you have actually given it.
A review of the facility assessment evidenced the facility Skills Competencies dated 10/2017, which documented in part, Medication management skills evaluation documents validation of medication management techniques and knowledge completed during job specific orientation and annually. The Medication Management Skills Evaluation CLS-228 (5/14), documented in part, Documents at time of administration on MAR/eMAR. Initiates incident report for medication administration errors.
A review of the facility's Medication and Treatment Administration Guidelines dated 3/2018, documented in part, Medications and treatments administered are documented immediately following administration or per state specific standards.
The facility enacted a plan of correction, which contained the following 5 points:
1. Nurse practitioner was immediately notified of medication administration error on 7/2/20 once discovered.
LPN #4 and RN #2 administered medications at 5:00 PM and 9:00 PM. LPN #4 and RN #2 were both assigned to Resident #47. LPN #4 failed to document administration of medications at 5:00 PM and again at 9:00 PM. RN #2 administered 5:00 PM and 9:00 PM medications to Resident #47 as they had not been documented as given and she was unaware that LPN #4 was also assigned to Resident #47.
2. All Residents with medication administration of their prescribed medications including anti-hypertensive, diabetic, anti-hyperlipidemia, anti-epileptic, anti-psychotic and insulin have the potential to be affected by this deficient practice.
3. All Nurses educated in person or via phone on 7/3/20 regarding the facility's Medication Administration policy [to include proper documentation after administration] dated 3/2018. LPN #4, an agency nurse, the nurse responsible for administration of the first dose of the 5:00 PM and the 9:00 PM medications was second check was terminated from the facility.
4. For the next month, an audit of medication administered and documented were reviewed by the director of nursing. The medication types reviewed included: anti-hypertensive, diabetic/insulin, anti-hyperlipidemia, anti-epileptic and anti-psychotic. All results and findings were presented and reviewed at the Quality meeting in August 2020.
5. Completion date 7/8/20.
The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding medication administration and documentation and failed to reveal any concerns. A medication pour/pass observation was completed during this survey and no concerns were identified including no concerns for the documentation of medications administered. No further significant medication errors were identified. Review of current residents failed to identify any concerns.
Past Noncompliance
References:
(1) Bipolar disorder is a mental disorder characterized by periods of mania and depression. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 71.
(2) Seizures: a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Diabetes mellitus: inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160.
(4) Atherosclerosis cardiac disease: disorder of the cardiac arteries caused by a buildup of plaque which results in the vessels becoming non-elastic. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 52.
(5) Losartan potassium tablets are indicated for the treatment of hypertension in adults Overdosage: Limited data are available in regard to overdosage in humans. The most likely manifestation of overdosage would be hypotension and tachycardia; bradycardia could occur from parasympathetic (vagal) stimulation. If symptomatic hypotension should occur, supportive treatment should be instituted. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cda520b7-ae84-4bd7-b298-11934f4fcc57
(6) Depakote ER [extended release] is a valproate and is indicated for the treatment of acute manic or mixed episodes associated with bipolar . Overdosage with valproate may result in somnolence, heart block, deep coma, and hypernatremia. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0dc024ce-efc8-4690-7cb5-639c728fccac
(7) Metformin hydrochloride extended-release tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. BOXED WARNING: Postmarketing cases of metformin-associated lactic acidosis have resulted in death, hypothermia, hypotension, and resistant bradyarrhythmias This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f0371d2a-276b-4acb-80f8-e24fb8ceae19
(8) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 443.
(9) HUMALOG is a rapid acting human insulin analog indicated to improve glycemic control in adults and children. 5 Warnings and Precautions: 5.3 Hypoglycemia: Hypoglycemia is the most common adverse reaction associated with insulins, including HUMALOG. 10. Overdosage: Excess insulin administration may cause hypoglycemia and hypokalemia. Mild episodes of hypoglycemia usually can be treated with oral glucose. More severe episodes may be treated with intramuscular/subcutaneous glucagon or concentrated intravenous glucose. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f
(10) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 32.
(11) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 67
(12) Gabapentin is indicated for: Management of postherpetic neuralgia in adults Adjunctive Gabapentin is indicated for: Management of postherpetic neuralgia in adults Adjunctive therapy in the treatment of partial onset seizures, with and without secondary generalization, in adults and pediatric patients 3 years and older with epilepsy Overdosage: Symptoms have included double vision, tremor, slurred speech, drowsiness, altered mental status, dizziness, lethargy, and diarrhea. Fatal respiratory depression has been reported with gabapentin overdose, alone and in combination with other CNS depressants. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=f1bce199-9f88-4a94-9006-8e148dedd45f&version=3
(13) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 429.
(14) Ziprasidone capsules are indicated for the treatment of schizophrenia, as monotherapy for the acute treatment of bipolar manic or mixed episodes. Overdoasge: (in part) cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring to detect possible arrhythmias. Hypotension . should be treated with appropriate measures such as intravenous fluids. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6485d78e-ca4e-4217-ad80-c784a15fa6a4&version=7
(15) BISOPROLOL FUMARATE is indicated in the management of hypertension. Overdosage: The most common signs expected with overdosage of a beta-blocker are bradycardia, hypotension, congestive heart failure, bronchospasm, and hypoglycemia. This information was obtained from the website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d82243b9-3e56-4a2b-8750-cb95ec106885
* This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/iatrogenic
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 observation, staff interview, facility document review, and clinical record review, it was determined the facility staf...
Read full inspector narrative →
**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 the facility staff failed to ensure one of 25 residents in the survey sample, (Resident #47), was free of a significant medication error.
On the evening of 7/2/2020, Resident #47 was administered all of her multiple physician prescribed evening medications twice, by two nurses, LPN [licensed practical nurse] #4 and RN [registered nurse] #4, resulting in a significant medication error. Resident #47 was subsequently was transferred to a local hospital for evaluation/treatment. The hospital record documented Resident #47 was sleepy, weak and confused in the emergency room, displayed a drop in blood sugar, blood pressure and slow hear rate (bradycardia) readings; IV (intravenous) fluids, including dextrose were administered, the resident was then admitted to the hospital for monitoring due to the medications overdose.
The findings include:
Resident #47 was admitted to the facility on [DATE] and transferred to the hospital on 7/2/20. Resident #47's diagnoses included but were not limited to: bipolar disorder (1), seizures (2), diabetes mellitus (3) and atherosclerosis cardiac disease (4).
Resident #47's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/15/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring limited assistance with mobility, transfers, dressing; supervision with personal hygiene and bathing and as independent in eating and locomotion. An annual assessment completed on 5/11/20 prior to the incident on 7/2/20 coded the resident as scoring a 9 out of 15 on the BIMS indicating Resident #47 was moderately impaired for cognition. Section N0350 Insulin: coded the resident as receiving insulin injections 7 out of 7 days of the look back period.
The physician orders for Resident #47 in July 2020, documented in part the following:
Medications scheduled administration time 5:00 PM:
- Losartan (anti-hypertensive) (5) 100 milligram table by mouth in the afternoon for hypertension
- Multivitamin (dietary supplement) 1 tablet by mouth in the afternoon for supplement,
- Divalproax [Depakote] (anti-epileptic) (6) 625 milligram delayed response tablet twice a day for seizure prevention,
- Metformin (anti-diabetic) (7) extended release tablet 500 milligram by mouth twice a day for diabetes mellitus,
- Olopatadine (treats allergic conjunctivitis) (8) solution 0.1% instill 1 drop in both eyes twice a day for allergies,
- Humalog Mix 75/25- inject 50 units subcutaneously twice a day before breakfast and dinner, notify MD if blood sugar less than 60 or greater than 400. Hold Humalog 75/25 if blood sugar is less than 100.
- Humalog (insulin) (9) 100 units/milliliter inject per sliding scale: if BS (blood sugar) 150-200 =4 units, BS 201-250=6 units, BS 251-300=8 units, BS 301-350=10 units, BS 351-400=12 units. If < 60 or > 350 or greater call physician, subcutaneously before meals for diabetes.
Medications scheduled administration time 9:00 PM:
- Atorvastin (anti-hyperlipidemic) (10) 10 milligram tablet by mouth at bedtime to lower cholesterol
- Cetirizine (antihistamine) (11) 5 milligram tablet at bedtime for allergies
- Gabapentin (anti-epileptic) (12) 600 milligram tablet at bedtime for nerve pain
- Melatonin (treatment for insomnia) (13) milligram tablet by mouth at bedtime for sleep
- Ziprasidone (antipsychotic) (14) 40 milligram capsule at bedtime for bipolar
- Bisoprolol (antihypertensive) (15) 10 milligram twice a day for hypertension
A FRI (facility reported incident) with an incident dated 7/2/20, and a reported date of 7/3/20, documented in part, Resident was given evening medication [all medications listed above] twice by two nurses. Resident's nurse practitioner requested the resident be sent to the hospital to be monitored due to the medication and her low blood pressure/pulse. Resident was admitted at the hospital for observation. Patient has no negative outcomes at this time. Employee action initiated or taken: Suspension/removed from schedule while investigation ongoing. Improvement plan and education initiated. If applicable date notification provided to: Responsible party: 7/3/2020, Physician: 7/3/2020, APS [adult protective services]: 7-3-2020, DHP [Department of Health Professions]: 7/3/2020
Review of the FRI investigation and follow up, documented in part, the following:
Facility investigation: Completed on: the date 7/8/2020 was handwritten on the form. An included attachment documented in part the following:
7-8-2020
FRI day 5
On 7/2/2020 it was reported that a resident was given medication twice by two different nurses. During the investigation it was found that the resident was written on two different assignment sheets, [name of LPN #4] gave the medication first, without documenting the medication in the system. [Name of RN #2] gave the medication second. The MD [medical doctor] was notified and gave an order to send the resident to the ER [emergency room]. Resident [#47] was sent to the hospital and remained there two nights under observation status. Resident [#47] returned to the facility on 7/4/2020 with no adverse reactions from the medication error and has remained stable. The DON [director of nursing] removed both nurses from the schedule while the investigation was ongoing, reconfigured the assignment sheets as well as educated the nursing staff on proper medication documentation. The investigation is complete.
Another attachment titled, Trigger Call Guideline/Agenda documented in part the following:
•
Event Type: Medication Error
•
Date and Time of Event: 7/2/20@ [at] 9pm
•
Patient Name: [Name of Resident #47]
•
Cognitive Status/BIMS (date last completed): 9 as of 5/11/20
•
Timeline of Events: [Name of LPN #4] (Agency Nurse) administered the following medications to [name of Resident #47] at around 5:20pm:
•
4 units of Humalog insulin
•
Humalog Mix 75/25- 50 units
•
Metformin ER [extended release] 500 mg (milligram)
•
MVI (multivitamin)
•
Depakote 625 mg
•
Losarten Potassium 100mg
•
Bisoprolol Fumrate 10mg
•
OlapTADINE HCL (hydrochloride) eye gtts (drops)
•
[Name of LPN #5] administered the following medications around 8pm:
•
Atrovastin Calcium10mg
•
Gabapentin 600mg
•
Melatonin 1mg
•
Ziprasidone HCL 40mg
Around 9pm [Name of RN #2] asked [Name of LPN #4] to compare assignments to make sure that no one was missed. At that time they noticed that they both had [Name of Resident #47] on their assignment sheets and they both had given her [Resident #47] her scheduled medications. They both [RN #2 and LPN#4] both went immediately to assess the resident. The resident [Resident #47] was sleeping. She [Resident #47] was easily aroused and responsive to questions. Vital signs were taken at that time. BP 95/47, 57, 16, 96% on RA [blood pressure, pulse, respirations and oxygen saturation on room air]. [Name of nurse practitioner] was notified immediately and orders were received to sent [Sic] resident to ER [emergency room]. When EMT's [emergency medical technicians] arrived resident was able to answer questions and she walked to the stretcher. EMS [emergency medical services] took her [Resident #47] blood sugar which was 146. Resident was transported to [Name of hospital]. [Name of RN #2] called report to the ER Nurse to inform her of what medications the resident [Resident #47] received in duplicate.
[Name of Resident #47's] Emergency Contact was notified of details of the incident this morning by [name of staff LPN]. DON called [Name of Resident #47's emergency contact] around 10am to explain the incident to her. During the investigation it was discovered that [Name of Resident #47] only received her Humalog 75/25 50 units once by [Name of LPN #4]. [* Note the sliding scale insulin was administered twice by both nurses for a total of 8 units of Humalog 100units/ ml].
Education has been initiated on Medication Administration to include signing off medications as you administer them to include giving medications timely as scheduled. The assignments sheets for the units were updated
The final investigation included: Statements by RN (registered nurse) #2 and LPN (licensed practical nurse) #4, both involved in the medication error event. The MAR (medication administration record) for July 2020 for Resident #47 with initials sign on code of KO9 corresponding to RN #2. The Assignment sheets for RN #2 and LPN #4.
A review of the clinical record failed to evidence any progress notes documenting the events of 7/2/20, regarding a medication error and/ or the residents transfer to the hospital.
A review of vital signs on 7/2/20 at 6:23 AM, documented in part, Blood pressure 138/65, pulse 70. Resident #47's blood sugar at 4:30 PM was documented as 179.
A review of a Discharge return anticipated MDS assessment with an assessment reference date of 7/2/20, documented in part, Unplanned transfer to acute hospital.
A review of the hospital records for Resident #47, evidenced admission to an acute care hospital on 7/2/20-7/4/20.
The emergency room record documented in part: EKG: Sinus bradycardia (slow heart rate (16)) rate of 51.
Emergency Department (ED) physician notes dated 7/2/20 11:28 PM, documented in part, She [Resident # 47] presents after getting a double dose of her medications which include extended release Metformin and Losartan. Her blood sugar dropped from 108 to 81. Her blood pressures have been on the soft side with maps (mean arterial pressures) around 65. She is getting a fluid bolus and I have ordered maintenance D5 (dextrose 5%) normal saline. Virginia Poison Control was contacted and suggests admission as Metformin was extended release and requires at least 12 hours of observation. She reports feeling sleepy, weak and somewhat confused.
The ED (emergency room) RN [registered nurse) note dated 7/2/20 at 11:00 PM documented in part, RN spoke with 'RN#2' taking care of patient from the facility. States that patient received a double dose of her evening medication. 'RN#2' states patient was given medications around 6:00 PM and again at 9:00 PM.
A review of the hospital Discharge summary dated [DATE], documented in part, Admitting diagnosis and hospital course: Accidental overdose and hypoglycemia secondary to iatrogenic [Referring to a physical or mental condition caused by a physician or healthcare provider*] insulin. Discharge Diagnosis/Plan: Accidental overdose-patient now back to baseline. EKG (electrocardiogram) x two with normal QT intervals. Diabetes Type 2-resume sliding scale insulin. Initially insulin held on admission. Hypertension-blood pressure soft due to overdose. Received IV (intravenous) fluids in ED. BP stable at this time.
LPN #4, an agency nurse, was not available for an interview and was not employed at the facility.
An interview was conducted on 4/22/21 at 4:56 PM with RN #2, the nurse supervisor. RN #2 was the second nurse who administered medications to Resident #47 on 7/2/20. When asked if she remembered the medication error on 7/2/20, RN #2 stated, Oh yes, that was the error with the agency nurse who gave medicines and didn't chart, either time. I came to give the medications to the resident [Resident #47] on my assignment sheet and since they were not signed off, I gave the 6:00 PM and 9:00 PM medications. I did not know we were both assigned to the resident until about 9:00 PM. If I had seen the medications signed off, I would have asked the other nurse about the assignment and the medications. I checked on the resident and saw that she did not look well, so I called the nurse practitioner and we transferred her to the hospital. When asked if she remembered any changes or education that were made because of the medication error, RN #2 stated, Yes, they changed the assignment sheet and the number of medication carts. We also reviewed the medication administration policy.
On 4/20/21 at 10:40 AM, during the entrance conference, when asked what standards of practice were followed, ASM (administrative staff member) #2, the director of nursing and ASM #3, the quality consultant stated, We use [NAME] and [NAME] & [NAME].
Administrative staff members (ASM) # 1, the administrator was made aware of the above concerns on 4/22/21 at 5:56 PM.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:08 AM.
According to Basic Nursing, Essentials for Practice, 6th edition ([NAME] and [NAME], 2007, pages 349-360) A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician's or health care provider's complete order on the appropriate medication form, the MAR. The MAR includes the patient's name, room, and bed number, as well as the names, dosages, frequencies, and routes of administration for each medication. When transcribing orders, ensure the names of medications, dosages, routes, and times are legible. The nurse checks all orders for accuracy and thoroughness. When orders are transcribed, the same information needs to be checked again by the nurse. It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation .Use the MAR to prepare and administer medications. When preparing medications in bottles or containers, compare the label of the medication container with the medication administration order three times: (1) before removing the container from the drawer or shelf, (2) as you remove the amount of medication ordered from the container, and (3) before returning the container to storage .After you administer medications, indicate which medications you gave on your patient's MAR per agency policy to show that you gave the medications as ordered. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about your patient's care. There are many nursing actions you take to ensure the right documentation. Make sure that the information on your patient's MAR corresponds exactly with the prescriber's order and with the label on the medication's container. Record the administration of each medication as soon as you give the medication. Never document that you have given a medication until you have actually given it.
A review of the facility assessment evidenced the facility Skills Competencies dated 10/2017, which documented in part, Medication management skills evaluation documents validation of medication management techniques and knowledge completed during job specific orientation and annually. The Medication Management Skills Evaluation CLS-228 (5/14), documented in part, Documents at time of administration on MAR/eMAR. Initiates incident report for medication administration errors.
A review of the facility's Medication and Treatment Administration Guidelines dated 3/2018, documented in part, Medications and treatments administered are documented immediately following administration or per state specific standards.
The facility enacted a plan of correction, which contained the following 5 points:
1. Nurse practitioner was immediately notified of medication administration error on 7/2/20 once discovered.
LPN #4 and RN #2 administered medications at 5:00 PM and 9:00 PM. LPN #4 and RN #2 were both assigned to Resident #47. LPN #4 failed to document administration of medications at 5:00 PM and again at 9:00 PM. RN #2 administered 5:00 PM and 9:00 PM medications to Resident #47 as they had not been documented as given and she was unaware that LPN #4 was also assigned to Resident #47.
2. All Residents with medication administration of their prescribed medications including anti-hypertensive, diabetic, anti-hyperlipidemia, anti-epileptic, anti-psychotic and insulin have the potential to be affected by this deficient practice.
3. All Nurses educated in person or via phone on 7/3/20 regarding the facility's Medication Administration policy dated 3/2018. LPN #4, an agency nurse, the nurse responsible for administration of the first dose of the 5:00 PM and the 9:00 PM medications was second check was terminated from the facility.
4. For the next month, an audit of medication administered and documented were reviewed by the director of nursing. The medication types reviewed included: anti-hypertensive, diabetic/insulin, anti-hyperlipidemia, anti-epileptic and anti-psychotic. All results and findings were presented and reviewed at the Quality meeting in August 2020.
5. Completion date 7/8/20.
The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding medication administration and documentation and failed to reveal any concerns. A medication pour/pass observation was completed during this survey. No further significant medication errors were identified. Review of current residents failed to identify any concerns.
Past Noncompliance
References:
(1) Bipolar disorder is a mental disorder characterized by periods of mania and depression. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 71.
(2) Seizures: a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Diabetes mellitus: inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160.
(4) Atherosclerosis cardiac disease: disorder of the cardiac arteries caused by a buildup of plaque which results in the vessels becoming non-elastic. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 52.
(5) Losartan potassium tablets are indicated for the treatment of hypertension in adults Overdosage: Limited data are available in regard to overdosage in humans. The most likely manifestation of overdosage would be hypotension and tachycardia; bradycardia could occur from parasympathetic (vagal) stimulation. If symptomatic hypotension should occur, supportive treatment should be instituted. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cda520b7-ae84-4bd7-b298-11934f4fcc57
(6) Depakote ER [extended release] is a valproate and is indicated for the treatment of acute manic or mixed episodes associated with bipolar . Overdosage with valproate may result in somnolence, heart block, deep coma, and hypernatremia. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0dc024ce-efc8-4690-7cb5-639c728fccac
(7) Metformin hydrochloride extended-release tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. BOXED WARNING: Postmarketing cases of metformin-associated lactic acidosis have resulted in death, hypothermia, hypotension, and resistant bradyarrhythmias This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f0371d2a-276b-4acb-80f8-e24fb8ceae19
(8) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 443.
(9) HUMALOG is a rapid acting human insulin analog indicated to improve glycemic control in adults and children. 5 Warnings and Precautions: 5.3 Hypoglycemia: Hypoglycemia is the most common adverse reaction associated with insulins, including HUMALOG. 10. Overdosage: Excess insulin administration may cause hypoglycemia and hypokalemia. Mild episodes of hypoglycemia usually can be treated with oral glucose. More severe episodes may be treated with intramuscular/subcutaneous glucagon or concentrated intravenous glucose. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f
(10) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 32.
(11) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 67
(12) Gabapentin is indicated for: Management of postherpetic neuralgia in adults Adjunctive Gabapentin is indicated for: Management of postherpetic neuralgia in adults Adjunctive therapy in the treatment of partial onset seizures, with and without secondary generalization, in adults and pediatric patients 3 years and older with epilepsy Overdosage: Symptoms have included double vision, tremor, slurred speech, drowsiness, altered mental status, dizziness, lethargy, and diarrhea. Fatal respiratory depression has been reported with gabapentin overdose, alone and in combination with other CNS depressants. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=f1bce199-9f88-4a94-9006-8e148dedd45f&version=3
(13) [NAME] Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 429.
(14) Ziprasidone capsules are indicated for the treatment of schizophrenia, as monotherapy for the acute treatment of bipolar manic or mixed episodes. Overdoasge: (in part) cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring to detect possible arrhythmias. Hypotension . should be treated with appropriate measures such as intravenous fluids. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6485d78e-ca4e-4217-ad80-c784a15fa6a4&version=7
(15) BISOPROLOL FUMARATE is indicated in the management of hypertension. Overdosage: The most common signs expected with overdosage of a beta-blocker are bradycardia, hypotension, congestive heart failure, bronchospasm, and hypoglycemia. This information was obtained from the website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d82243b9-3e56-4a2b-8750-cb95ec106885
(16) Bradycardia: bradycardia [brad?e-kahr´de-ah] slowness of the heartbeat, so that the pulse rate is less than 60 per minute. This information was obtained from the website:https://medical-dictionary.thefreedictionary.com/bradycardia
* This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/iatrogenic
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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 ...
Read full inspector narrative →
**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 provide privacy and dignity for a Foley catheter for one of 25 residents in the survey, Resident #80.
On 4/21/21, Resident #80 was observed lying in bed with an uncovered Foley catheter bag visible from the hall. The facility staff failed to provide privacy and dignity for the Foley catheter bag.
The findings include:
Resident #80 was admitted to the facility on [DATE]. Resident #80's diagnoses included but were not limited to chronic kidney disease, diabetes and paralysis. Resident #80's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/6/21, coded the resident's cognition as severely impaired. Section H coded the resident as having a urinary catheter.
On 4/21/21 at 9:01 a.m. and 3:26 p.m., observations, Resident #80's bed room door was half way open. The resident was lying in bed with an uncovered Foley catheter (1) bag attached to the bed frame. The catheter bag and urine in the bag was visible from the hall.
On 4/21/21 at 5:02 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated a Foley catheter bag should be hooked on the bottom of the bed and should be covered in a bag for privacy. When asked how she would feel if her catheter bag was visible from the hall, LPN #3 stated, I don't want everybody to know.
On 4/21/21 at 5:19 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated a Foley catheter bag should be in a privacy bag for dignity. When asked how she would feel if her catheter bag was visible from the hall, CNA #3 stated, Not too good.
On 4/21/21 at 6:08 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility policy titled, CATHETER CARE: INDWELLING CATHETER documented in part, Catheter bags should be covered with a catheter dignity bag to preserve the dignity of the patient.
No further information was presented prior to exit.
Reference:
(1) A Foley catheter is a tube placed in the bladder that drains urine from the bladder into a bag outside of the body. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000140.htm
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility...
Read full inspector narrative →
**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 maintain a clean environment for one of 25 current residents in the survey sample, (Resident #25). The facility staff failed to clean Resident #25's feeding tube pump.
The findings include:
Resident #25 was admitted to the facility on [DATE], with diagnoses including but not limited to: epilepsy, COPD (chronic obstructive pulmonary disease) (1), and diabetes (2). The most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 2/16/21, coded Resident #25 as being moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). He was coded as being totally dependent on the assistance of staff members for all activities of daily living (ADL). He was coded as receiving feedings by way of a PEG (percutaneous endoscopic gastrostomy) (3) tube.
Resident #25 declined to be interviewed during the survey.
On the following dates and times, Resident #25 was observed lying on his back in bed. During all observations, Resident #25 was receiving PEG tube feeding with the use of a pump to provide the prescribed amount of feeding. On 4/20/21 at 11:40 a.m., 4/20/21 at 12:47 p.m., 4/20/21 at 1:48 p.m., and 4/21/20 at 9:11 a.m., observations of Resident #25's feeding tube pump revealed it contained multiple spots of yellowish-brown, thick and sticky residual on the front of the pump.
A review of Resident #25's clinical record revealed the following physician's order, dated 4/12/21: Enteral Feed Order One time a day for nutrition. Glucerna 1.5 60 mls (milliliters)/hour (per hour).
A review of Resident #25's comprehensive care plan dated 2/22/21 revealed, in part: Need for feeding tube/potential for complications of feeding tube use.
On 4/21/21 at 9:11 a.m., RN (registered nurse) #6, the unit manager, was accompanied to observe Resident #25's feeding tube pump. When asked if the feeding tube pump was clean, RN #6 looked all over the pump, and then stated, I'm not sure. When asked about the multiple yellowish-brown, thick, sticky spots observed on the front of the pump, RN #2 stated, It just looks like some of the feeding dripped on it. Oh well, I can go clean it.
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked if she takes care of Resident #25 regularly, she stated she does. When asked if she had noticed Resident #25's feeding tube pump, LPN #2 stated, To be honest, I looked at it to make sure it was the right rate, and I just kept moving. She stated she had been told that the pump was dirty with feeding residual. LPN #2 stated it is not at all okay for a feeding tube pump to be dirty in this manner.
On 4/22/21 at 5:17 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and ASM #3, the quality consultant, were informed of these concerns.
A review of the facility policy, Tube Feedings: Feedings, revealed, in part: Completion of Procedure: Return equipment to designated area and clean/dispose as indicated.
No further information was provided prior to exit.
(1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.
(3) A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. PEG feeding tube insertion is done in part using a procedure called endoscopy. Feeding tubes are needed when you are unable to eat or drink. This may be due to stroke or other brain injury, problems with the esophagus, surgery of the head and neck, or other conditions. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000900.htm
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and facility document review, it was determined that the facility staff failed to orient a resident pr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and facility document review, it was determined that the facility staff failed to orient a resident prior to transfer for one of 25 current residents reviewed, Resident #55. The facility staff failed to provide evidence that all required information including the resident notification and orientation prior to transfer was provided to Resident #55 upon transfer to the hospital on 4/12/21.
The findings include:
Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: paraplegia (paralysis of the lower limbs) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and right below the knee amputation (surgical removal of part of the right leg below the knee) (3).
Resident #55's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/17/20, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. The resident was coded as requiring extensive assistance in bed mobility, transfer, dressing, hygiene and bathing.
During the initial resident observation on 4/20/21 at 10:35 AM, Resident #55 was not in room. On 4/20/21 at 11:55 AM, Resident #55 was not in her room and during lunch tray delivery a lunch tray not delivered.
An interview was conducted on 4/20/21 with CNA (certified nurse assistant) #1. When asked the location of Resident #55, CNA #1 stated, She went to the hospital last week, I believe it was on 4/12/21.
A review of Resident #55's clinical record revealed a MDS, a discharge return anticipated assessment with an assessment reference date of 4/12/21.
Further review of Resident #55's clinical record failed to reveal documentation to evidence that all required information the resident notification and orientation prior to transfer was provided to Resident #55 upon transfer to the hospital on 4/12/21. In addition, there was no progress note describing transfer to the hospital, nor a physician order to transfer to the hospital. A physician order dated 4/22/21, documented in part, Admit to skilled nursing facility (SNF).
On 4/22/21 at 8:37 AM, an interview was conducted with RN (registered nurse) #3. When asked if a written notification and orientation is provided to the resident prior to transfer to the hospital, RN #3 stated, It should be documented and in the medical record.
On 4/22/20 at 5:15 PM, an interview was conducted with ASM (administrative staff member) #3, the quality consultant. When asked if a written notification and orientation is provided to the resident prior to transfer to the hospital, ASM #1 stated, Our internal process is to document it. We have a folder that they put all the transfer information in. I will look for the paper copies and have for you in the morning.
On 4/23/21 at 10:00 AM, ASM #3 stated, There is no further information regarding any transfer documentation for Resident #55 for the 4/12/21 hospitalization.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:20 AM.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 432.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 29.
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 and facility document review, it was determined the facility staff failed to develop a baseline care pl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 25 current residents in the survey sample, Resident #24. The facility failed to develop a baseline care plan for Resident #24 to address the care required for the resident's tracheostomy and failed to address ROM (range of motion), which was triggered on the 2/6/21, admission assessment for the baseline care plan.
The findings include:
Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3).
Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Section G- Functional Status: coded the resident as dependent with bed mobility, transfers, dressing, eating, personal hygiene and bathing; walking and locomotion did not occur. A review of MDS Section O- Special treatments, procedures and programs: coded the resident as tracheostomy 'yes' and oxygen therapy 'yes'.
A review of the physician orders dated 2/6/21, documents in part, Suction as needed to maintain patent airway and every shift. Trach (tracheostomy) care daily and as needed. Remove disposable and dispose of inner cannula. Replace with new inner cannula as needed to reduce the risk of infection.
A review of Resident #24's baseline care plan dated 2/6/21 failed to evidence documentation of tracheostomy care. Baseline care plan, documents in part, FOCUS-The resident has altered respiratory status/difficulty breathing related to tracheostomy status. INTERVENTIONS-Administer medications as ordered elevate head of bed 30 degrees, monitor changes in orientation, anxiety and air hunger. Monitor for signs and symptoms of respiratory distress and report to physician. Monitor and report abnormal breathing patterns to physician. Position resident with proper body alignment for optimal breathing pattern. Range of Motion was not identified as a focus on the baseline care plan provided.
A review of the admission evaluation dated 2/6/21, documented in part, Clinical evaluation-neurological: identify areas of weakness- right upper extremity, left upper extremity, right lower extremity, left lower extremity (all four areas were checked). Clinical evaluation-musculoskeletal: upper extremity range of motion- impairment on both sides, lower extremity range of motion-impairment on both sides. Trigger for baseline care plan: Alteration in musculoskeletal status. The resident's mobility will be improved/restored by use of (specify: prosthesis, use of adaptive equipment). Trigger for baseline care plan was not included on baseline care plan.
A review of the medical practitioner full assessment dated [DATE], documented in part, Musculoskeletal decreased ROM and weakness-atrophy or spasticity were checked. Abnormal findings documented-contracture of right hand.
An interview was conducted on 4/21/21 at 8:53 AM with LPN (licensed practical nurse) #1, regarding the purpose of the baseline care plan. LPN #1 stated, The base line care plan is the initial plan of care for the resident based on physician orders and initial assessment. It gives us the interventions we need for the resident.
An interview was conducted on 4/21/21 at 11:53 AM with ASM (administrative staff member) #3, the quality consultant. When asked who completes the baseline care plan, ASM #3 stated, The baseline care plan is completed by the admissions nurse. When asked who provides revisions to the care plan, ASM #3 stated, The IDT (inter-disciplinary team) or anyone who finds a change should revise the care plan.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concern on 4/21/21 at 5:40 PM.
The facility's Interdisciplinary Care Planning policy dated 3/2018, documents in part, A baseline care plan must include the minimum healthcare information necessary to properly care for a patient including, but not limited to:
Initial goals based on admission orders, physician orders, therapy services, social services and dietary orders.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 37.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 574.
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 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 provide ADL (activities of daily living) care for one of 25 residents in the survey sample, Resident #19. On three Sundays in March 2021, the facility staff failed to provide assistance with transfers, dressing or personal hygiene, to Resident #19, who was assessed as requiring extensive assistance of one staff with personal hygiene and dressing.
The findings include:
Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to end stage renal disease, diabetes and muscle weakness. Resident #19's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/7/21, coded the resident as being cognitively intact. Section G coded Resident #19 as requiring extensive assistance of one staff with personal hygiene and dressing. Section G further documented transfers did not occur during the assessment look back period.
Resident #19's comprehensive care plan dated 2/2/21 documented, ADL Self care deficit. Assist with daily hygiene, grooming, dressing, oral care and eating as needed.
On 4/20/21 at 1:44 p.m., an interview was conducted with Resident #19. Resident #19 stated the staff did not assist her with getting washed, changing her gown or getting out of bed on some weekends. Resident #19 stated these (ADLs) are only certain to occur during the week when she receives therapy.
Review of Resident #19's March 2021 ADL records failed to reveal the resident was assisted with transfers on Sunday 3/7/21, personal hygiene, dressing and transfers on Sunday 3/14/21 and transfers on Sunday 3/28/21, as evidenced by blank spaces on the ADL records for these dates.
On 4/21/21 at 5:16 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated residents should be cleaned and dressed, or have their gown changed, daily and residents should be assisted out of bed daily if they want to get up. CNA #4 stated the completion of ADLs should be documented in the computer system ADL records and you can't say the care was provided if it was left blank.
On 4/21/21 at 6:08 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility document titled, Focus on F Tag 677 documented, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility...
Read full inspector narrative →
**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 provide foot care and treatment, in accordance with professional standards of practice for one of 25 current residents in the survey sample, Resident #67. The facility staff failed to trim Resident #67's toenails to an optimal length to prevent infection or disease.
The findings include:
Resident #67 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including ESRD (end stage renal disease) (1), diabetes (2), lymphedema (3), and bipolar disorder (4). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 4/12/21, Resident #67 was coded as having no cognitive impairment for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff members for personal hygiene.
Resident #67 refused to be interviewed regarding her toenails.
On 4/21/21 at 2:46 p.m., observation was made of Resident #67's feet. The resident was lying on her back in the bed, and RN (registered nurse) #1 was assessing the resident's feet, and RN #6 was assisting her. Observation revealed Resident #67's right great toenail was at least 1/2 inch beyond her nail bed, thick, with some black areas scattered over the nail. The right third and fourth toenails were at least 1/2 inch beyond the nail bed. The left great toenail and left third toenails were discolored, with some dark areas. The left fourth toenail was at least 1/2 inch beyond the nail bed. RN #6 stated, The nails are definitely too long. They need to be cut. I will have to call the podiatrist. RN #1 stated she thought the doctor needed to look at all the nails because of the nail discolorations on both feet. RN #1 stated there could be a fungal infection or some other process going on. She stated that the toenails were too long, and needed to be cut as soon as possible to promote foot health for Resident #67.
A review of Resident #67's comprehensive care plan dated 11/24/20 revealed, in part: ADL (activities of daily living) self care deficit related to physical limitations .Will receive assistance necessary to meet ADL needs .2 staff assistance with ADLS .Assist with daily hygiene, grooming, dressing, oral care, and eating as needed.
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked if she takes care of Resident #67, she stated she does. When asked if she remembers assessing Resident #67's toenails recently, she stated she could not remember. LPN #2 stated the CNAs (certified nursing assistants) will tell her if a resident's toenails need attention. She stated there is a list on the unit for residents who need a podiatrist to see them. LPN #2 stated she does not think Resident #67 is on that list, but she could be added. When asked if discoloration of a resident's toenails means anything significant, LPN #2 stated it could simply mean the toenails need to be cleaned, or it could mean that the resident has some sort of infection.
On 4/21/21 at 3:08 p.m., CNA #3 was interviewed. She stated she frequently works with Resident #67, and she looks at the resident's toenails every time I take care of her and bathe her. CNA #3 stated she tries to give the resident a bath every day. CNA #3 stated if she noticed the resident's toenails getting too long, she would tell the nurse.
On 4/21/21 at 6:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and ASM #3, the quality consultant, were informed of these concerns.
A review of the facility policy Foot Care, revealed, in part: Purpose: To stimulate peripheral circulation, control odor, and observe for infection .Patient that is Diabetic .Wash feet daily with mild soap and warm water, do not soak. Dry feet gently and thoroughly, especially between toes .Do not cut toenails (only licensed nurses) .Suggested documentation: Unusual observations and/or complaints and subsequent interventions including communications with physician.
No further information was provided prior to exit.
REFERENCES
(1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease (ESRD). This information is taken from the website https://medlineplus.gov/ency/article/000500.htm.
(2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.
(3) Lymphedema (LE) is the accumulation of protein-rich fluid in tissues. The impaired function of lymph vessels interrupts the drainage of lymphatic system that is a part of the circulatory system just like the arterial and venous structures. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508242/#:~:text=Lymphedema%20(LE)%20is%20the%20accumulation,the%20arterial%20and%20venous%20structures.
(4) Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. This information is taken from the website https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to provide services to preven...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to provide services to prevent a decrease in range of motion (ROM) for one of 25 current residents in the survey sample, Resident #24.
The facility failed to provide ROM services after identification of weakness and impaired mobility on admission for Resident #24.
The findings include:
Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3).
Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS Section G- Functional Status: coded the resident as dependent with bed mobility, transfers, dressing, eating, personal hygiene and bathing; walking and locomotion did not occur. A review of MDS Section O- Special treatments, procedures and programs: coded the resident as tracheostomy 'yes' and oxygen therapy 'yes'.
A review of the admission evaluation dated 2/6/21, documented in part, Clinical evaluation-neurological: identify areas of weakness- right upper extremity, left upper extremity, right lower extremity, left lower extremity, (all four areas checked). Clinical evaluation-musculoskeletal: upper extremity range of motion- impairment on both sides, lower extremity range of motion-impairment on both sides. Trigger for baseline care plan: Alteration in musculoskeletal status. The resident's mobility will be improved/restored by use of (specify: prosthesis, use of adaptive equipment).
A review of the medical practitioner full assessment dated [DATE], documented in part, Musculoskeletal decreased ROM and weakness-atrophy or spasticity were checked. Abnormal findings documented-contracture of right hand.
A review of Resident #24's comprehensive care plan dated 2/6/21, with a revised on date of 2/19/21, revealed Range of Motion was not identified as a focus on the comprehensive care plan provided.
An interview was conducted on 4/20/21 at 2:00 PM with CNA (certified nursing assistant) #1. When asked when ROM was performed for Resident #24, CNA #1 stated, When morning care is provided, we do it then. When asked if this is documented anywhere, CNA #1 stated, No, it is not. When asked about devices to prevent further contracture of Resident #24's right hand, CNA #1 stated, We sometimes put a rolled up washcloth in their hand to help with contracture. When asked where the device was on 4/20/21 at 2:00 PM, CNA #1 stated, It's not there.
An interview was conducted on 4/21/21 at 8:53 AM with LPN (licensed practical nurse) #1. When asked the purpose of ROM, LPN #1 stated, ROM is to prevent weakness and stiffening of muscles and joints. When asked what devices are used with hand contractures, LPN #1 stated, We use a carrot or rolled up washcloth. She doesn't have one; I will get it for her.
An observation was made on 4/21/21 at 4:20 PM, no carrot or rolled up washcloth was in Resident #24's right hand, a rolled up hand towel was in place in the bend of both elbows.
An observation was made on 4/22/21 at 8:10 AM, no carrot or rolled up washcloth was in Resident #24's right hand, a rolled up hand towel was in place in the bend of both elbows.
An interview was conducted on 4/22/21 at 8:17 AM with RN (registered nurse) #3, the unit manager. When asked the purpose of providing ROM, RN #3 stated, We provide ROM to those residents who are not mobile and need ROM to keep their muscles and joints mobile and reduce the chance of contractures.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concern on 4/22/21 at 5:20 PM.
The facility's Range of Motion: Active/Passive policy revised 2/2019, documents in part, Purpose: To improve or maintain joint mobility and minimize potential for contractures. Suggested documentation: care provided in plan of care. Document in progress notes if unusual observations and/or complaints and subsequent interventions including communications with medical practitioner or rehabilitation therapist as clinically indicated.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 37.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 574.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to address a significant weight gain for one of 25 residents in the survey sample, Resident #19.
The facility staff failed to address Resident #19's monthly weight gain of 11.10 percent in March 2021.
The findings include:
Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to end stage renal disease, diabetes and muscle weakness. Resident #19's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/7/21 coded the resident as being cognitively intact.
Review of Resident #19's clinical record revealed a weight of 219 pounds on 2/2/21 and a weight of 243.3 pounds on 3/16/21 (totaling 11.10 percent gain).
Further review of Resident #19's clinical record including nurses' notes, dietary notes and nutritional assessments failed to reveal the 11.10 percent gain on 3/16/21 was addressed.
Resident #19's comprehensive care plan dated 2/5/21 documented, Resident is at risk for alterations in nutritional / hydration status related to ESRD- HD (end stage renal disease- hemodialysis), DM2 (diabetes), therapeutic diet, impaired mobility, prefers eating all meals each day from an outside source via delivery.
The former RD (registered dietician) was no longer employed at the facility.
On 4/21/21 at 2:41 p.m., an interview was conducted with OSM (other staff member) #5 (the current RD). OSM #5 stated residents should be weighed every month unless specified and he will be reviewing residents' weights every month. OSM #5 stated that if he notes a weight gain of five percent or more in a month then he asks for the resident to be re-weighed, then goes through a process of elimination to try to determine the cause of the weight gain. OSM #5 stated that after he identifies the potential cause then he implements interventions to address the gain.
On 4/21/21 at 6:08 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility policy regarding weight measurement documented,
WEIGHT CHANGE FOLLOW-UP AND DOCUMENTATION
-Identify the change on the Daily Interdisciplinary Eagle Room Report
-Enter significant weight changes on the Weight Change Eagle Room tool. Use the Acute Condition Change Eagle Room tool for weekly weight changes that need follow-up.
-Notify the physician and responsible party.
-Consider scheduling for weekly weights until resolved.
Registered dietician evaluates and documents in the nutrition progress notes.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
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 complete an annual CNA (certified nursing aide) performance review for one of five CNA record...
Read full inspector narrative →
Based on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for one of five CNA record reviews.
The facility staff failed to complete an annual performance review for CNA #5.
The findings include:
Review of CNA #5's record revealed the last performance review was completed for an appraisal period of March 2018 to March 2019.
On 4/21/21 at 6:08 p.m., an interview was conducted with ASM (administrative staff member) #3 (the quality consultant). ASM #3 stated a list of CNAs who need a performance review is given to the director of nursing each month then the director of nursing either completes the performance reviews or has a unit manager or floor nurse complete the reviews. At this time, ASM #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 were made aware of the above concern.
An email sent from ASM #1 on 4/22/21 at 8:27 a.m. documented, (CNA #5) performance evaluation: She was on a leave of absence 7/1/2020-9/1/2020 and again 2/15/2021-3/15/2021. She is on our list of evals (evaluations) to be completed due to the LOA (leave of absence) times.
On 4/22/21 at 3:26 p.m., ASM #3 confirmed CNA #5's performance review could have been completed in between the times CNA #5 was not on a leave of absence.
The facility policy titled, 1200.06 PERFORMANCE APPRAISALS documented, It is the policy of (name of company) that every employee's performance be reviewed and discussed with him/her by his/her immediate supervisor. 12. In the event of a promotion with an associated pay increase after the first anniversary date with the company, the employee's next merit increase will be 12 months from the effective date of his/her increase .
No further information was presented prior to exit.
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, staff interview, clinical record review, and facility document review, it was determined that the facility...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer medication in a sanitary manner to prevent the spread of infection for one of 5 residents in the Medication Administration task, (Resident #28).
During the medication observation RN #4 used her bare finger to tap at a Cardizem pill that was not easily dislodged from the packaging, her bare finger was in direct contact with the Cardizem pill that was partially protruding from the package. RN #4 dislodged the Cardizem pill from the package into the pill cup. RN #4 then administered
The findings include:
The facility staff failed to administer a medication, Cardizem (1), in a sanitary manner for Resident #28.
Resident #28 was admitted to the facility on [DATE] with the diagnoses of but not limited to congestive heart failure, chronic obstructive pulmonary disease, dementia, high blood pressure, schizophrenia, atrial fibrillation and diabetes. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 2/24/21. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing, supervision for all other areas of activities of daily living except for eating, which was coded as being independent.
A review of the clinical record revealed an order dated 9/12/19 for Cardizem CD Capsule Extended Release 24 Hour 360 MG (milligrams) Give 1 capsule by mouth one time a day for htn (high blood pressure)
On 4/21/21 at 8:30 AM, RN #4 (Registered Nurse) was observed preparing and administering medications for Resident #28. She was observed sanitizing her hands prior to starting preparation of the medications for Resident #28. As she went through the process of preparing the medications for Resident #28, RN #4 was observed touching the drawers of the medication cart, the computer, the packages of medications, the medication cup and other supplies on top of her medication cart, thus re-contaminating her hands. The Cardizem was the 5th medication she prepared for Resident #28, having touched the medication cart, drawers, and packages from other medications first. Observation revealed the Cardizem capsule was not easily removed from the package and RN #4 used her bare finger to tap at the pill, her bare finger was in direct contact with the Cardizem pill that was partially protruding from the package. RN #4 dislodged the Cardizem pill from the package into the pill cup. RN #4 then administered the medications, including the Cardizem that she had touched, to the Resident #28.
On 4/21/21 09:26 AM in an interview with RN #4 she stated that you should not touch pills with your hands. RN #4 stated that she did not realize she had done that.
A review of the facility policy Medication and Treatment Administration Guidelines documented, Medications are administered in accordance with standards of practice
According to [NAME] and Perry's, Fundamentals of Nursing, 6th edition, page 847, For safe administration, the nurse uses aseptic technique when handling and giving medications.
Skill 1: Administering Oral Medications: 6. Prepare the required medications: b. Multidose containers: When removing tablets or capsules . pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Do not touch tablets or capsules with hands. Rationale: Pouring capsules or tablets into your hand is unsanitary. 12. Transport medications to patient bedside carefully . 14. Perform hand hygiene and put on PPE [personal protective equipment] if indicated. Rationale: Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission based precautions. 20. Administer the medications. [NAME] Photo Atlas of Medication Administration, Sixth Edition, [NAME] B [NAME], EdD, MSN RN, Wolters Kluwe, 2019, pages 2, 3, 4 and 6.
On 4/21/21 at 6:00 PM at the end of day meeting, ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
(1) Cardizem - is used to treat high blood pressure.
Information obtained from https://medlineplus.gov/druginfo/meds/a684027.html
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to provide evidence that the comprehensive care plan goals were provided to the receiving hospital ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to provide evidence that the comprehensive care plan goals were provided to the receiving hospital when Resident #55 was transferred to the hospital on 4/12/21.
Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: paraplegia (paralysis of the lower limbs) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and right below the knee amputation (surgical removal of part of the right leg below the knee) (3).
Resident #55's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/17/20, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. The resident was coded as requiring extensive assistance in bed mobility, transfer, dressing, hygiene and bathing; walking and locomotion did not occur and independent in eating.
During the initial resident observation on 4/20/21 at 10:35 AM, Resident #55 was not in room. On 4/20/21 at 11:55 AM, Resident #55 was not in her room and during lunch tray delivery a lunch tray not delivered.
An interview was conducted on 4/20/21 with CNA (certified nurse assistant) #1. When asked the location of Resident #55, CNA #1 stated, She went to the hospital last week, I believe it was on 4/12/21.
A review of Resident #55's clinical record revealed a MDS, a discharge return anticipated assessment with an assessment reference date of 4/12/21.
Further review of Resident #55's clinical record failed to reveal documentation to evidence that required information, comprehensive care plan goals were provided to the hospital staff for Resident #55's 4/12/21 transfer. In addition, there was no progress note describing transfer to the hospital, nor a physician order to transfer to the hospital. A physician order dated 4/22/21, documented in part, Admit to skilled nursing facility (SNF).
On 4/22/20 at 5:15 PM, an interview was conducted with ASM (administrative staff member) #3, the quality consultant, regarding the above concern. ASM #1 stated she would look for any information.
On 4/23/21 at 10:00 AM, ASM #3 stated, There is no further information any transfer documentation for Resident #55 for the 4/12/21 hospitalization.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:20 AM.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 432.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 29.
Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the required information to the receiving facility for facility-initiated transfers of five of 25 sampled residents, (Residents #80, #11, #33, #60 and #55).
The facility staff failed to provide evidence that all required information was provided to the hospital staff for facility initiated transfers of Resident #80 on 2/25/21, Resident #60's on 3/21/21, and failed to evidence the comprehensive care plan goals were provided to the receiving facility for facility initiated transfer of Resident #33 on 2/27/21, Resident #55 on 4/12/21, and Resident #11 on 1/17/21, and failed to ensure the physician documented the rationale for the Resident #11's transfer in the clinical record.
The findings include:
1. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #80 was transferred to the hospital on 2/25/21.
Resident #80 was admitted to the facility on [DATE]. Resident #80's diagnoses included but were not limited to chronic kidney disease, diabetes and paralysis. Resident #80's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/6/21, coded the resident's cognition as severely impaired.
A note signed by the nurse practitioner on 2/25/21 documented, Patient is a [AGE] year old female being seen today per nursing request due to acute onset of large amounts of coffee ground vomitus. Patient is still vomiting during this visit .
A nurse's note dated 2/25/21 documented, RP (Responsible party) made aware. Res. sent to (name of hospital) per np (nurse practitioner) and family request.
Further review of Resident #80's clinical record failed to reveal documentation to evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff.
On 4/22/21 at 2:07 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated a face sheet, copy of doctor's orders, labs [laboratory tests], doctor's notes, nurses' notes, a transfer form and the care plan should be provided to hospital staff when residents transfer to the hospital. When asked how staff evidences the information was provided to hospital staff, LPN #5 stated she was not 100 percent sure how to answer that but sometimes a little box on the transfer form will pop up. Resident #80's clinical record did not contain a transfer form for 2/25/21.
On 4/22/21 at approximately 5:45 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility document titled, Focus on F622 documented, The facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health are institution or provider .
No further information was presented prior to exit.
2. The facility staff failed to evidence Resident #11's comprehensive care plan goals were provided to the receiving facility, for the residents transfer to the hospital on 1/17/21, and failed to ensure that the physician wrote a note regarding the need for the 1/17/21 hospitalization for Resident #11.
Resident #11 was admitted to the facility on [DATE] with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21. Resident #11 was coded as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded Resident #11 as requiring extensive assistance.
A review of the clinical record revealed a nurse's note dated 1/17/21 at 5:08 PM that documented part, Resident was found on floor by CNA (Certified Nursing Assistant) at 12:45PM when aide entered the room to pass out the lunch trays. Aide came to nurses station and got writer. Upon entering room resident was found face down on the floor. Resident was lying on the left side of the bed by the a.c (air conditioner) unit. Writer asked resident was she okay and she stated i'm (sic) in pain. Writer asked resident what happened and resident stated I was having a muscle spasm. Resident was assited (sic) to her back by 4 staff members and injuries were noted. Resident had a laceration to the left side of her head and multiple bruises on her head, arms, and hands. Resident was assisted back to bed with mechanical lift and 2 staff members. On call NP (nurse practitioner) notified at 12:50PM and gave order to transfer resident to (name of hospital). Residents daughter (name) notified at 1:00PM via telephone conversation of transfer. Resident left facility at 1:30AM by stretcher accompanied by paramedics.
A nurse's note dated 1/19/21 at 3:01 PM documented, UM (unit manager) received a call from (name), daughter, with concerns about her mother's fall yesterday Resident was also admitted due to + (positive for) UTI (urinary tract infection) UM spoke with (name), SW (social worker) about above and (social worker) said that (daughter) is not the Legal Guardian Incident Report showed notification of (daughter) instead of Legal Guardian. UM called LG (legal guardian), (name), to inform of the fall on 1/17/21 and updated on (Resident #11) status as relayed by (daughter). He was appreciative of the call
The resident was readmitted on [DATE].
Further review of the clinical record revealed an Acute Transfer Form dated 1/17/21 that provided demographic and medical information. This form did not evidence the comprehensive care plan goals were provided.
Further review of the clinical record failed to evidence that the physician wrote a note documenting the basis for the transfer, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
On 4/22/21 at 2:07 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). LPN #5 was asked what information is provided to the hospital staff. LPN #5 stated, We send the face sheet, copy of doctor's orders, labs [laboratory tests], doctor's notes, nurses notes, anything pertaining to what they would need for that instance, and a transfer form. The transfer form contains what hospital they are being sent to, their name, date of birth , medical reason for the transfer, vital signs, anything that needs to be on it. When asked if the comprehensive care plan goals are provided to the hospital, LPN #5 stated, Yes we do. When asked staff evidence they are provided, LPN #5 stated, I'm not 100% sure how to answer that. Sometimes it's a little box that will pop up on the transfer form about the care plan. When asked if nursing ensures the physician writes a note about the reason for transfer, LPN #5 stated, We can't control what the physician does.
On 4/22/21 at 5:20 PM ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
3. The facility staff failed to evidence that Resident #33's comprehensive care plan goals were provided to the receiving facility upon transfer to the hospital on 2/27/21.
Resident #33 was admitted to the facility on [DATE] with the diagnoses of but not limited to chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and dementia. The most recent MDS (Minimum Data Set), an annual assessment with an ARD (Assessment Reference Date) of 3/1/21, coded Resident #33 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living.
A review of the clinical record revealed a nurse's note dated 2/27/21 at 11:12 AM documented, X-Ray results to Right knee of Mildly impacted acute appearing right knee fracture MD (medical doctor) was called new order to send resident to E.R. (emergency room). RP (responsible party) called to up-date.
A nurse's note dated 2/27/21 at 12:10 PM documented, Resident sent out to (name of hospital) on stretcher via EMS (emergency medical service) x 2 d/t (due to) fracture to RLE (right lower extremity) of unknown cause. Before transfer resident was assessed by this nurse, skin warm and dry to touch, no open areas noted at this time, VS (vital signs) witin (sic) normal limits. All ordered medicatons (sic) given to resident prior to transfer, no adverse reactions noted. No acute distress noted at time of transfer. RP/MD/Unit Manager (Responsible Party/Medical Doctor/Unit Manager) notified and updated on status. See previous notes.
A nurse's note dated 2/27/21 documented, Resident returned to facility from (hospital) ED (emergency department) with a right knee immobilizer in place. Resident was seen at the ED for Avulsion fracture of tibial tuberosity, with instructions to follow up with (name of doctor), MD in 2 days around 3/1/2021. Specialty Orthopedic Surgery, (address and number) Radiology Results: Acute minimally displaced fracture of anterior tibial tubercle consistent with patellar tendon avulsion. No new orders from ED at this time (Physician) and family will be notified of resident's return to the facility.
A review of the x-ray results dated 2/27/21 revealed, in addition to the injury itself, that the resident had osteopenia.
A physician's progress note dated 3/3/21 documented, being seen today per nursing request due to right anterior tibial tubercle fracture that occurred on 2/27/21. X-ray report indicates presence of osteopenia. Patient being seen today due to risks that include pain, osteoporosis and repeated fractures. Patient is laying in bed during this exam, she denies pain at this time. Swelling noted to right knee with +1 edema to right ankle. Slight grimacing noted when RLE (right lower extremity) is moved. Currently using Tylenol and positioning for pain control. Denies any further concerns today.
Further review of the clinical record revealed an Acute Transfer Form dated 2/27/21 that provided demographic and medical information. This form did not evidence that the comprehensive care plan goals were provided to the hospital at the time of Resident #33's transfer on 2/27/21.
The resident was readmitted on the same day, 2/27/21, after an emergency room only visit.
On 4/22/21 at 2:07 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). LPN #5 was asked what information is provided to the hospital staff. LPN #5 stated, We send the face sheet, copy of doctor's orders, labs [laboratory tests], doctor's notes, nurses notes, anything pertaining to what they would need for that instance, and a transfer form. The transfer form contains what hospital they are being sent to, their name, date of birth , medical reason for the transfer, vital signs, anything that needs to be on it. When asked if the comprehensive care plan goals are provided to the hospital, LPN #5 stated, Yes we do. When asked staff evidence they are provided, LPN #5 stated, I'm not 100% sure how to answer that. Sometimes it's a little box that will pop up on the transfer form about the care plan.
On 4/22/21 at 5:20 PM ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
References:
(1) Tylenol - is used to relieve mild to moderate pain.
Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html
4. The facility staff failed to evidence that all the required documentation was completed and/or provided to the receiving facility for Resident #60's hospital transfer on 3/21/21.
Resident #60 was admitted to the facility on [DATE] with the diagnoses of but not limited to Moyamoya disease, quadriplegia, seizures, high blood pressure, chronic kidney disease, depression, cerebrovascular disease, and human immunodeficiency virus. The most recent MDS (Minimum Data Set) assessment, was a quarterly assessment with an ARD (Assessment Reference Date) of 3/29/21. Resident #60 was coded as cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which required extensive assistance.
A review of the clinical record revealed the following notes:
•
A nurse's note dated 3/24/21 at 8:04 PM documented, Resident transferred via stretcher and was readmit to the SNF (Skilled Nursing Facility) This note was upon return from the hospital and did not address the reason the resident was sent to the hospital on 3/21/21 and what documentation was sent.
•
A Nurse Practitioner note 3/25/21 at 11:30 AM documented, .Medical Stability Visit with Medication Reconciliation at Transfer of Care & (and) Acute Physical Deconditioning (re)admitted to (facility) on 3/24/21 for rehabilitation with generalized weakness and unsteady gait S/P (status post) hospitalization for hematemesis. admission records reveal pt (patient) was treated for cholelithiasis Patient's condition subsequently improved Additional Xrays not listed above - 3/22/21 ABD (abdominal) US (ultra sound) -FLUID FILLED GALL BLADDER WITH CHOLELITHIASIS
Further review of the clinical record failed to reveal any evidence of pre-hospitalization nurse's notes documenting regarding the residents condition. Further review failed to evidence any hospital transfer documentation and paperwork that was completed and sent with the resident on transfer.
On 4/23/21 at 10:07 AM ASM #1 (Administrative Staff Member, the Administrator) stated that the electronic health record system was down from 3/18/21 through 3/22/21. The resident was transferred to the hospital on 3/21/21. During this same meeting, ASM #3, the corporate Quality Consultant Nurse stated that no paper record documentation during the computer downtime could be located regarding this hospital transfer. ASM #3 also stated that there is an envelope with a checklist on the front that staff were supposed to use to compile all transfer documents in and maintain a copy of the completed checklist but that no one was following that procedure, so therefore, there was no documentation at all that evidenced what was going on with the resident, what the facility staff did for the resident, and what, if any, documents were prepared and provided to the hospital upon transfer.
No further information was provided by the end of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to provide evidence that notification was provided to the resident and or the resident representati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to provide evidence that notification was provided to the resident and or the resident representative and ombudsman upon Resident #55's transfer to the hospital on 4/12/21.
Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: paraplegia (paralysis of the lower limbs) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and right below the knee amputation (surgical removal of part of the right leg below the knee) (3).
Resident #55's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/17/20, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. The resident was coded as requiring extensive assistance in bed mobility, transfer, dressing, hygiene and bathing; walking and locomotion did not occur and independent in eating.
During the initial resident observation on 4/20/21 at 10:35 AM, Resident #55 was not in room. On 4/20/21 at 11:55 AM, Resident #55 was not in her room and during lunch tray delivery a lunch tray not delivered.
An interview was conducted on 4/20/21 with CNA (certified nurse assistant) #1. When asked the location of Resident #55, CNA #1 stated, She went to the hospital last week, I believe it was on 4/12/21.
A review of Resident #55's clinical record revealed a MDS, a discharge return anticipated assessment with an assessment reference date of 4/12/21.
Further review of Resident #55's clinical record failed to reveal documentation to evidence that all required information, resident and or responsible person notification, ombudsman notification were provided as soon as practicable before transfer or discharge. In addition, there was no progress note describing transfer to the hospital, nor a physician order to transfer to the hospital. A physician order dated 4/22/21, documented in part, Admit to skilled nursing facility (SNF).
On 4/22/21 at 8:37 AM, an interview was conducted with RN (registered nurse) #3. When asked if the bed hold is documented, RN #3 stated, It should be documented and in the medical record.
On 4/22/20 at 5:15 PM, an interview was conducted with ASM (administrative staff member) #3, the quality consultant. When asked if a written notice is provided for the bed hold upon transfer to the hospital, ASM #1 stated, Our internal process is to document it. We have a folder that they put all the transfer information in. I will look for the paper copies and have for you in the morning.
On 4/23/21 at 10:00 AM, ASM #3 stated, There is no further information regarding any transfer documentation for Resident #55 for the 4/12/21 hospitalization.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:20 AM.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 432.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 29.
Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide written notification of transfer to residents and/or their representatives for five of 25 residents in the survey sample, (Residents #80, #11, #33, #60 and #55).
The facility staff failed to evidence that written notification regarding the transfer was provided to the resident and/or representative for transfers to the hospital for: Resident #80, on 2/25/21, Resident #11, on 1/17/21, Resident #33, on 2/27/21, Resident #60, on 3/21/21 and Resident #55 on 4/12/21.
The findings include:
1. Resident #80 was transferred to the hospital on 2/25/21. The facility staff failed to evidence that written notification regarding the transfer was provided to the resident and/or representative.
Resident #80 was admitted to the facility on [DATE]. Resident #80's diagnoses included but were not limited to chronic kidney disease, diabetes and paralysis. Resident #80's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/6/21, coded the resident's cognition as severely impaired.
A note signed by the nurse practitioner on 2/25/21 documented, Patient is a [AGE] year old female being seen today per nursing request due to acute onset of large amounts of coffee ground vomitus. Patient is still vomiting during this visit .
A nurse's note dated 2/25/21 documented, RP (Responsible party) made aware. Res. sent to (name of hospital) per np (nurse practitioner) and family request.
Further review of Resident #80's clinical record failed to reveal documentation to evidence the resident and/or representative was provided written notification regarding the transfer.
On 4/22/21 at 2:07 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated nurses notify residents' representatives of hospital transfers via phone but do not provide any written notice.
On 4/22/21 at 2:32 p.m., an interview was conducted with OSM (other staff member) #4 (the social worker). OSM #4 stated residents' representatives are notified of hospital transfers via phone and nursing sends a packet with residents to the hospital.
On 4/22/21 at approximately 5:45 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility document titled, Focus on F623 documented, Before a facility transfer or discharges a resident, the facility must-- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.
No further information was presented prior to exit.
2. The facility staff failed to evidence that a written notification was provided to the resident and or resident representative upon Resident #11's transfer to the hospital on 1/17/21.
Resident #11 was admitted to the facility on [DATE] with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21. The resident was coded as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance.
A review of the clinical record revealed a nurse's note dated 1/17/21 at 5:08 PM that documented, Resident was found on floor by CNA (Certified Nursing Assistant) at 12:45PM when aide entered the room to pass out the lunch trays. Aide came to nurses station and got writer. Upon entering room resident was found face down on the floor. Resident was lying on the left side of the bed by the a.c (air conditioner) unit. Writer asked resident was she okay and she stated i'm in pain. Writer asked resident what happened and resident stated I was having a muscle spasm. Resident was assited to her back by 4 staff members and injuries were noted. Resident had a laceration to the left side of her head and multiple bruises on her head, arms, and hands. Resident was assisted back to bed with mechanical lift and 2 staff members. On call NP (nurse practitioner) notified at 12:50PM and gave order to transfer resident to (name of hospital). Residents daughter (name) notified at 1:00PM via telephone conversation of transfer. Resident left facility at 1:30AM by stretcher accompanied by paramedics.
A nurse's note dated 1/19/21 at 3:01 PM documented, UM (unit manager) received a call from (name), daughter, with concerns about her mother's fall yesterday Resident was also admitted due to + (positive for) UTI (urinary tract infection) UM spoke with (name), SW (social worker) about above and (social worker) said that (daughter) is not the Legal Guardian Incident Report showed notification of (daughter) instead of Legal Guardian. UM called LG (legal guardian), (name), to inform of the fall on 1/17/21 and updated on (Resident #11) status as relayed by (daughter). He was appreciative of the call
The resident was readmitted on [DATE].
Further review of the clinical record revealed an Acute Transfer Form dated 1/17/21 that provided demographic and medical information. There was no evidence on this form of written notification provided to the Resident Representative.
Further review of the clinical record failed to reveal any evidence that a written notification of the transfer on 1/17/21, was provided to the Resident Representative.
On 4/22/21 at 2:07 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). When asked if nursing provides any written notice of the transfer to the resident or Resident Representative, LPN #5 stated, No.
On 4/22/21 at 2:33 PM, an interview was conducted with OSM #4 (Other Staff Member), the social worker. When asked if she has a role in providing written notification to Resident Representative, OSM #4 stated that she just calls them.
On 4/22/21 at 5:20 PM ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
3. The facility staff failed to evidence that a written notification was provided to the resident and or the resident representative upon Resident #33's transfer to the hospital on 2/27/21.
Resident #33 was admitted to the facility on [DATE] with the diagnoses of but not limited to chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and dementia. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 3/1/21. Resident #33 was coded as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living.
A review of the clinical record revealed a nurse's note dated 2/27/21 at 11:12 AM documented, X-Ray results to Right knee of Mildly impacted acute appearing right knee fracture MD (medical doctor) was called new order to send resident to E.R. (emergency room). RP (responsible party) called to up-date.
A nurse's note dated 2/27/21 at 12:10 PM documented, Resident sent out to (name of hospital) on stretcher via EMS (emergency medical service) x 2 d/t (due to) fracture to RLE (right lower extremity) of unknown cause. Before transfer resident was assessed by this nurse, skin warm and dry to touch, no open areas noted at this time, VS (vital signs) witin (sic) normal limits. All ordered medicatons (sic) given to resident prior to transfer, no adverse reactions noted. No acute distress noted at time of transfer. RP/MD/Unit Manager (Responsible Party/Medical Doctor/Unit Manager) notified and updated on status. See previous notes.
A nurse's note dated 2/27/21 documented, Resident returned to facility from (hospital) ED (emergency department) with a right knee immobilizer in place. Resident was seen at the ED for Avulsion fracture of tibial tuberosity, with instructions to follow up with (name of doctor), MD in 2 days around 3/1/2021. Specialty Orthopedic Surgery, (address and number) Radiology Results: Acute minimally displaced fracture of anterior tibial tubercle consistent with patellar tendon avulsion. No new orders from ED at this time (Physician) and family will be notified of resident's return to the facility.
A review of the x-ray results dated 2/27/21 revealed, in addition to the injury itself, that the resident had osteopenia.
A physician's progress note dated 3/3/21 documented, being seen today per nursing request due to right anterior tibial tubercle fracture that occurred on 2/27/21. X-ray report indicates presence of osteopenia. Patient being seen today due to risks that include pain, osteoporosis and repeated fractures. Patient is laying in bed during this exam, she denies pain at this time. Swelling noted to right knee with +1 edema to right ankle. Slight grimacing noted when RLE (right lower extremity) is moved. Currently using Tylenol and positioning for pain control. Denies any further concerns today.
The resident was readmitted on the same day, 2/27/21, after an emergency room only visit.
Further review of the clinical record revealed an Acute Transfer Form dated 2/27/21 that provided demographic and medical information. There was no evidence on this form of written notification provided to the Resident Representative for Resident #33's transfer to the hospital.
Further review of the clinical record failed to reveal any evidence that written notification was provided to the Resident Representative.
On 4/22/21 at 2:07 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). When asked if nursing provides any written notice of the transfer to the resident or Resident Representative, LPN #5 stated, No.
On 4/22/21 at 2:33 PM, an interview was conducted with OSM #4 (Other Staff Member), the social worker. When asked if she has a role in providing written notification to Resident Representative, OSM #4 stated that she just calls them.
On 4/22/21 at 5:20 PM ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
References:
(1) Tylenol - is used to relieve mild to moderate pain.
Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html
4. The facility staff failed to evidence that a written notification was provided to the resident and or resident representative upon a hospital transfer on 3/21/21 for Resident #60.
Resident #60 was admitted to the facility on [DATE] with the diagnoses of but not limited to Moyamoya disease, quadriplegia, seizures, high blood pressure, chronic kidney disease, depression, cerebrovascular disease, and human immunodeficiency virus. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 3/29/21. The resident was coded as being cognitively intact in ability to make daily life decisions. Resident #60 was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance.
A review of the clinical record revealed the following notes:
A nurse's note dated 3/24/21 at 8:04 PM documented, Resident transferred via stretcher and was readmit to the SNF (Skilled Nursing Facility) This note was upon return from the hospital and did not address the reason the resident was sent to the hospital on 3/21/21 and what documentation was sent.
A Nurse Practitioner note 3/25/21 at 11:30 AM documented, .Medical Stability Visit with Medication Reconciliation at Transfer of Care & (and) Acute Physical Deconditioning (re)admitted to (facility) on 3/24/21 for rehabilitation with generalized weakness and unsteady gait S/P (status post) hospitalization for hematemesis. admission records reveal pt (patient) was treated for cholelithiasis Patient's condition subsequently improved Additional Xrays not listed above - 3/22/21 ABD (abdominal) US (ultra sound) -FLUID FILLED GALL BLADDER WITH CHOLELITHIASIS
Further review of the clinical record failed to reveal any evidence that written notification was provided to the Resident Representative for Resident #60's recent hospital transfer.
On 4/22/21 at 2:07 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). When asked if nursing provides any written notice of the transfer to the resident or Resident Representative, LPN #5 stated, No.
On 4/22/21 at 2:33 PM, an interview was conducted with OSM #4 (Other Staff Member), the social worker. When asked if she has a role in providing written notification to Resident Representative, OSM #4 stated that she just calls them.
On 4/22/21 at 5:20 PM ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to provide evidence that the bed hold information was provided to Resident #55 upon transfer to the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to provide evidence that the bed hold information was provided to Resident #55 upon transfer to the hospital on 4/12/21.
Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: paraplegia (paralysis of the lower limbs) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and right below the knee amputation (surgical removal of part of the right leg below the knee) (3).
Resident #55's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/17/20, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. The resident was coded as requiring extensive assistance in bed mobility, transfer, dressing, hygiene and bathing; walking and locomotion did not occur and independent in eating.
During the initial resident observation on 4/20/21 at 10:35 AM, Resident #55 was not in room. On 4/20/21 at 11:55 AM, Resident #55 was not in her room and during lunch tray delivery a lunch tray not delivered.
An interview was conducted on 4/20/21 with CNA (certified nurse assistant) #1. When asked the location of Resident #55, CNA #1 stated, She went to the hospital last week, I believe it was on 4/12/21.
A review of Resident #55's clinical record revealed a MDS, a discharge return anticipated assessment with an assessment reference date of 4/12/21.
Further review of Resident #55's clinical record failed to reveal documentation to evidence that bed hold information was provided at the time of transfer or discharge. In addition, there was no progress note describing transfer to the hospital, nor a physician order to transfer to the hospital. A physician order dated 4/22/21, documented in part, Admit to skilled nursing facility (SNF).
On 4/22/21 at 8:37 AM, an interview was conducted with RN (registered nurse) #3. When asked if the bed hold is documented, RN #3 stated, It should be documented and in the medical record.
On 4/22/20 at 5:15 PM, an interview was conducted with ASM (administrative staff member) #3, the quality consultant. When asked if a written notice is provided for the bed hold upon transfer to the hospital, ASM #1 stated, Our internal process is to document it. We have a folder that they put all the transfer information in. I will look for the paper copies and have for you in the morning.
On 4/23/21 at 10:00 AM, ASM #3 stated, There is no further information regarding bed hold or any transfer documentation for Resident #55 for the 4/12/21 hospitalization.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:20 AM.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 432.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 29.
Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a written bed hold notice for a facility-initiated transfer for four of 25 residents in the survey sample, (Residents #80, #11, #60 and #55).
The facility staff failed to provide the resident and or the resident's representative written notification of the bed hold policy upon transfer to the hospital for: Resident #80's hospital transfer on 2/25/21, Resident #11's hospital transfer on 1/17/21, Resident #60's hospital transfer on 3/21/21, and Resident #55 upon transfer to the hospital on 4/12/21.
The findings include:
1. The facility staff failed to provide Resident #80 and/or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 2/25/21.
Resident #80 was admitted to the facility on [DATE]. Resident #80's diagnoses included but were not limited to chronic kidney disease, diabetes and paralysis. Resident #80's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/6/21, coded the resident's cognition as severely impaired.
A note signed by the nurse practitioner on 2/25/21 documented, Patient is a [AGE] year old female being seen today per nursing request due to acute onset of large amounts of coffee ground vomitus. Patient is still vomiting during this visit .
A nurse's note dated 2/25/21 documented, RP (Responsible party) made aware. Res. (resident) sent to (name of hospital) per np (nurse practitioner) and family request.
Further review of Resident #80's clinical record failed to reveal evidence that written notification of the bed hold policy was provided to the resident and/or the resident representative.
On 4/22/21 at 2:07 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated nurses are supposed to send a copy of the facility bed hold policy with residents when they are transferred to the hospital. LPN #5 stated nurses should document a note that the bed hold policy was provided but not all nurses do this.
On 4/22/21 at approximately 5:45 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility document titled, Focus of F625 documented, Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy .
No further information was presented prior to exit.
2. The facility staff failed to evidence that a written bed hold policy was provided to the Resident or Resident Representative for Resident #11's hospital transfer on 1/17/21.
Resident #11 was admitted to the facility on [DATE], with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21, coded the resident as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance.
A review of the clinical record revealed a nurse's note dated 1/17/21 at 5:08 PM, documented in part: . On call NP (nurse practitioner) notified at 12:50PM and gave order to transfer resident to (name of hospital). Residents daughter (name) notified at 1:00PM via telephone conversation of transfer. Resident left facility at 1:30AM by stretcher accompanied by paramedics.
A nurse's note dated 1/19/21 at 3:01 PM documented, UM (unit manager) received a call from (name), daughter, with concerns about her mother's fall yesterday Resident was also admitted due to + (positive for) UTI (urinary tract infection) UM spoke with (name), SW (social worker) about above and (social worker) said that (daughter) is not the Legal Guardian Incident Report showed notification of (daughter) instead of Legal Guardian. UM called LG (legal guardian), (name), to inform of the fall on 1/17/21 and updated on (Resident #11) status as relayed by (daughter). He was appreciative of the call
The resident was readmitted on [DATE].
Further review of the clinical record revealed an Acute Transfer Form dated 1/17/21 that provided demographic and medical information. This form did not include bed hold information.
Further review of the clinical record failed to reveal any evidence that a written bed hold policy was provided to the Resident #11 and or the Resident Representative for the 1/17/21 hospital transfer.
On 4/22/21 at 2:07 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). When asked if nursing provides the resident or Resident Representative a bed hold policy, LPN #5 stated, Yes. When asked how that is evidenced, LPN #5 stated, We send it with them. All that should be included in a note. When asked if the note should include everything that is sent, LPN #5 stated, You should but not everyone does.
On 4/22/21 at 2:53 PM, an interview was conducted with OSM #3 (Other Staff Member), the Admissions Coordinator, regarding her role for a resident discharged to the hospital. OSM #3 stated, There are many times I will call the family to see if they want to pay to hold the bed. When asked if she provides the family with a written bed hold policy notice, OSM #3 stated, When they state they want to hold the bed or they don't want to hold the bed. They can do it verbally or they can sign. No evidence was provided that a written bedhold policy was provided.
On 4/22/21 at 5:20 PM ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
3. The facility staff failed to evidence that a written bed hold policy was provided to the resident and or the Resident Representative for Resident #60's hospital transfer on 3/21/21.
Resident #60 was admitted to the facility on [DATE] with the diagnoses of but not limited to Moyamoya disease, quadriplegia, seizures, high blood pressure, chronic kidney disease, depression, cerebrovascular disease, and human immunodeficiency virus. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 3/29/21. Resident #60 was coded as cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance.
A review of the clinical record revealed the following notes:
A nurse's note dated 3/24/21 at 8:04 PM documented, Resident transferred via stretcher and was readmit to the SNF (Skilled Nursing Facility) This note was upon return from the hospital and did not address the reason the resident was sent to the hospital on 3/21/21 and what documentation was sent.
A Nurse Practitioner note 3/25/21 at 11:30 AM documented, .Medical Stability Visit with Medication Reconciliation at Transfer of Care & (and) Acute Physical Deconditioning (re)admitted to (facility) on 3/24/21 for rehabilitation with generalized weakness and unsteady gait S/P (status post) hospitalization for hematemesis. admission records reveal pt (patient) was treated for cholelithiasis Patient's condition subsequently improved Additional Xrays not listed above - 3/22/21 ABD (abdominal) US (ultra sound) -FLUID FILLED GALL BLADDER WITH CHOLELITHIASIS
Further review of the clinical record failed to reveal any evidence that a written bed hold policy was provided to the resident and or the Resident Representative for Resident #60's recent hospital transfer.
On 4/22/21 at 2:07 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). When asked if nursing provides the resident or Resident Representative a bed hold policy, LPN #5 stated, Yes. When asked how that is evidenced, LPN #5 stated, We send it with them. All that should be included in a note. When asked if the note should include everything that is sent, LPN #5 stated, You should but not everyone does.
On 4/22/21 at 2:53 PM, an interview was conducted with OSM #3 (Other Staff Member), the Admissions Coordinator, regarding her role for a resident discharged to the hospital. OSM #3 stated, There are many times I will call the family to see if they want to pay to hold the bed. When asked if she provides the family with a written bed hold policy notice, OSM #3 stated, When they state they want to hold the bed or they don't want to hold the bed. They can do it verbally or they can sign. No evidence was provided that a written bedhold policy was provided.
On 4/22/21 at 5:20 PM ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility failed to develop a comprehensive care plan to include trach [tracheostomy] care and ROM (range of motion) for R...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility failed to develop a comprehensive care plan to include trach [tracheostomy] care and ROM (range of motion) for Resident #24.
Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3).
Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS Section G- Functional Status: coded the resident as dependent with bed mobility, transfers, dressing, eating, personal hygiene and bathing; walking and locomotion did not occur. A review of MDS Section O- Special treatments, procedures and programs: coded the resident as tracheostomy 'yes' and oxygen therapy 'yes'.
A review of the physician orders dated 2/6/21, documents in part, Suction as needed to maintain patent airway and every shift. Trach [tracheostomy] care daily and as needed. Remove disposable and dispose of inner cannula. Replace with new inner cannula as needed to reduce the risk of infection.
A review of Resident #24's comprehensive care plan dated 2/6/21 and revised on 2/19/21, failed to evidence tracheostomy care for Resident #24 was addressed. The comprehensive care plan, documents in part, FOCUS-The resident has altered respiratory status/difficulty breathing related to tracheostomy status. INTERVENTIONS-Administer medications as ordered elevate head of bed 30 degrees, monitor changes in orientation, anxiety and air hunger. Monitor for signs and symptoms of respiratory distress and report to physician. Monitor and report abnormal breathing patterns to physician. Position resident with proper body alignment for optimal breathing pattern.
A review of the admission evaluation dated 2/6/21, documented in part, Clinical evaluation-neurological: identify areas of weakness- right upper extremity, left upper extremity, right lower extremity, left lower extremity (all four areas checked). Clinical evaluation-musculoskeletal: upper extremity range of motion- impairment on both sides, lower extremity range of motion-impairment on both sides.
A review of the medical practitioner full assessment dated [DATE], documented in part, Musculoskeletal decreased ROM and weakness-atrophy or spasticity were checked. Abnormal findings documented-contracture of right hand.
Range of Motion was not identified as a focus on the comprehensive care plan provided for Resident #24.
An interview was conducted on 4/21/21 at 8:53 AM with LPN (licensed practical nurse) #1, regarding the purpose of the comprehensive care plan. LPN #1 stated, The comprehensive care plan is the plan of care for the resident based on physician orders, assessment and unresolved goals from baseline care plan. It gives us the interventions we need for the resident.
An interview was conducted on 4/21/21 at 11:53 AM with ASM (administrative staff member) #3, the quality consultant. When asked who completes the comprehensive care plan, ASM #3 stated, The care plan is completed by the IDT (inter-disciplinary team) or the nurse. When asked who provides revisions to the care plan, ASM #3 stated, The IDT or anyone who finds a change should revise the care plan.
An interview was conducted on 4/22/21 at 8:17 AM with RN (registered nurse) #3, the interim unit manager, regarding the purpose of the comprehensive care plan. RN #3 stated, The care plan is individualized to the unique needs of the resident. A multi-disciplinary team develops the care plan to make it specific to the resident. The care plan should include trach (tracheostomy), care, suctioning, frequency of dressing change, inner cannula change and cleaning.
ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concern on 4/21/21 at 5:40 PM.
The facility's Interdisciplinary Care Planning policy dated 3/2018, documents in part, The comprehensive care plan describe the following: the services that are to be furnished to maintain the patient's highest practicable physical, mental and psychosocial wellbeing.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 37.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 574.
5. The facility staff failed to implement the comprehensive care plan for care and services of a tracheostomy for Resident #44.
Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (1) and tracheostomy (2).
Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/12/21 coded Resident #44 as being non-verbal and severely impaired of making daily decisions. Section G coded Resident #44 as being totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependent on one staff member for eating and personal hygiene. Section O coded Resident #44 as receiving oxygen, suctioning and tracheostomy care while a resident at the facility.
The comprehensive care plan for Resident #44 dated 12/15/2020 documented in part, Has/At risk for respiratory impairment related to tracheostomy. Date Initiated: 12/15/2020. Revision on: 03/16/2021. Under Interventions it documented in part, .Administer oxygen as per physician order: 5 L (liter) via cool mist humidifier. Date Initiated: 12/15/2020 .Maintain replacement trach (tracheostomy) tube and Ambu bag (3) at bedside. Date Initiated: 12/15/2020 .
The physician orders for Resident #44 documented in part, .Cool air mist via trach collar continuous with O2 (oxygen) titrated in at 5 liters every shift for respiratory failure. (4) Order Date: 12/03/2020 . PRN (as needed) as needed for trach care. Order Date: 05/28/2020 .
On 4/20/21 at approximately 10:45 a.m., an observation was conducted of Resident #44 in their room. Resident #44 was observed in bed and was observed to have a tracheostomy. Resident #44 was observed wearing a tracheostomy collar mask (oxygen delivery device) delivering oxygen at 5 lpm (liters per minute). Observation of the humidifier bottle attached to the oxygen tubing, revealed it was empty. Observation of the tracheostomy mask, tubing and humidifier bottle, failed to reveal a date on any of the items. A suction machine was observed on the nightstand beside Resident #44's bed with approximately 200 ml (milliliters) of yellowish colored liquid inside the canister. Suction tubing was observed attached to the canister and coiled around the suction equipment, no suction catheter was observed opened. Suction catheter kits, tracheostomy cleaning kits and replacement tracheostomy inner cannulas were observed stored in Resident #44's room. No ambu bag was observed in Resident #44's room.
Additional observations on 4/20/21 at 1:34 p.m. and 3:45 p.m. revealed the same findings as above. On 4/21/21 at approximately 9:30 a.m., observation revealed the humidifier bottle was half full. The tracheostomy mask, tubing and bottle remained undated and no ambu bag was observed in the room.
On 4/21/21 at approximately 3:15 p.m., an interview was conducted with RN (registered nurse) #6, the unit manager. RN #6 stated that ambu bags were kept on the emergency cart at the nurses' station and were not kept in Resident #44's room. RN #6 stated that if Resident #44's tracheostomy became dislodged or removed accidentally they would go to the supply closet to obtain another tracheostomy and to the emergency cart to get the ambu bag. RN #6 stated that the only emergency supplies kept in Resident #44's room were suction equipment, suction catheters and the tracheostomy cleaning kit and then proceeded to point out where they were kept in Resident #44's room. RN #6 stated that they did not keep ambu bags in any resident rooms in the facility.
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that oxygen supplies were changed weekly and were dated when put into use. LPN #8 stated that they were supposed to keep suction equipment, extra tracheostomy tubes and ambu bags in the rooms of residents with a tracheostomy. LPN #8 observed Resident #44's room and stated that there were extra tracheostomy inner cannulas in the wardrobe drawer along with suction catheters and tracheostomy cleaning kits, but there was no ambu bag. LPN #8 stated that there was no date on the oxygen mask, tubing or bottle. LPN #8 stated that the ambu bag was located on the emergency cart at the nurses' station. LPN #8 stated that the purpose of the care plan was to make sure the resident's needs were being met and to provide the best care to them. LPN #8 stated that if there was no ambu bag in the room they were not following the care plan.
The facility policy Tracheostomy Care dated updated 07/2017 documented in part, .Note: A spare tracheostomy tube of the same size and type should be kept at the patient's bedside for emergency purposes. An Ambu-bag should also be kept at the patient's bedside with attachment to fit trach .
The facility policy Oxygen Administration dated updated: 07/2017 documented in part, .Change all tubing and masks as per state protocol and label with date and initials .
The facility policy Interdisciplinary care planning dated updated 03/2018 documented in part, .The patient's care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also identifies the types and methods of care that the patient should receive . The policy further documented, .Once the care plan is developed, the staff must implement the interventions identified in the care plan. These may include, but is not limited to: administering medications and treatments .
On 4/22/21 at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
Reference:
1. Intracerebral hemorrhage- is bleeding in the brain caused by the breaking (rupture) of a blood vessel in the head. This information was obtained from the website: http://pacificschoolserver.org/med/ency/article/000796.htm.
2. Tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.
3. Ambu bag is a self-refilling bag-valve-mask unit with a 1-1.5 liter capacity, used for artificial respiration which, while suboptimal for the non-intubated patient, is effective for ventilating and oxygenating intubated patients, allowing both spontaneous and artificial respiration. This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/Ambu+bag
4. Respiratory failure: When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.
6. The facility staff failed to implement the comprehensive care plan for care and services of a tracheostomy for Resident #35.
Resident #35 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of base of tongue (1) and tracheostomy (2).
Resident #35's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/3/21 coded Resident #35 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Section O coded Resident #35 as receiving suctioning and tracheostomy care while a resident at the facility.
The comprehensive care plan for Resident #35 dated 5/29/2020 documented in part, Has/At risk for respiratory impairment related to tracheostomy secondary to tongue malignancy. Date Initiated: 05/29/2020. Revision on: 05/29/2020. Under Interventions it documented in part, .treatments per MD (medical doctor) orderers [sic] Date Initiated: 05/29/2020 . Administer medications/treatments per physicians orders. Date Initiated: 05/29/2020 .Maintain replacement trach [tracheostomy] tube and Ambu bag (3) at bedside. Date Initiated: 12/15/2020 .
The physician orders for Resident #35 documented in part, .Cool air mist via trach collar PRN (as needed) as needed for trach care. Order Date: 05/28/2020 .
On 4/20/21 at approximately 10:30 a.m., an observation was conducted of Resident #35 in their room. Resident #35 was observed sitting on the side of their bed wrapping a compression bandage around their knee. Resident #35 was observed with a tracheostomy in place. Resident #35 was observed to have a humidifier machine and suction machine on their nightstand beside the bed. A tracheostomy collar oxygen mask was observed to be hanging on the humidifier bottle of the machine. The mask was uncovered with visible debris on the mask. Observation of the humidifier bottle, mask and tubing, revealed they did not contain a date. Resident #35 was interviewed at this time. When asked if they used the humidifier and mask, Resident #35 nodded and stated Yes. When asked if the staff kept the water in the bottle and took care of the mask, Resident #35 nodded again and stated Yes. Resident #35 stated that they wore the mask at night. No ambu bag was observed in Resident #44's room.
Additional observations on 4/20/21 at 1:45 p.m. revealed the findings above. On 4/21/21 at approximately 10:30 a.m. and 3:15 p.m., observations of Resident #35's room revealed the mask hanging on the humidifier bottle attached to the machine uncovered but no visible debris on the mask. The tracheostomy mask, tubing and bottle remained undated and no replacement ambu bag was observed in the room.
On 4/21/21 at approximately 3:15 p.m., an interview was conducted with RN (registered nurse) #6, the unit manager. RN #6 stated that ambu bags were kept on the emergency cart at the nurses' station and were not kept in rooms of residents with a tracheostomy. RN #6 stated that if a resident's tracheostomy became dislodged or removed accidentally they would go to the supply closet to obtain another tracheostomy and to the emergency cart to get the ambu bag. RN #6 stated that the only emergency supplies kept in the rooms were suction equipment, suction catheters and the tracheostomy cleaning kit. RN #6 stated that they did not keep ambu bags in any resident rooms in the facility.
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that oxygen supplies were changed weekly and were dated when put into use. LPN #8 stated that they were supposed to keep suction equipment, extra tracheostomy tubes and ambu bags in the rooms of residents with a tracheostomy. LPN #8 observed Resident #35's room and stated that Resident #35 managed applying their humidifier mask and removing it themselves. LPN #8 stated that it should have had a date on it and should be changed weekly. LPN #8 stated that the staff should still monitor Resident #35 if they are applying and removing their mask to ensure that it is kept clean. LPN #8 stated that normally any oxygen supplies including masks were stored in bags with the date on them when not in use. LPN #8 stated there was no bag in Resident #35's room for their mask because they managed it themselves. LPN #8 stated that it should be on their care plan if the resident self-managed their treatment and did not comply with storage of the mask. LPN #8 asked Resident #35 if they wore their humidifier mask the previous night and Resident #35 stated, Yes. LPN #8 stated that they were going to obtain a new mask and tubing and date them so they would know when they needed to be changed. LPN #8 stated that the ambu bag was located at the nurses' station on the emergency cart and not in the resident's room and that they needed to put one in Resident #35's room.
The facility policy Tracheostomy Care dated updated 07/2017 documented in part, .Note: A spare tracheostomy tube of the same size and type should be kept at the patient's bedside for emergency purposes. An Ambu-bag should also be kept at the patient's bedside with attachment to fit trach .
The facility policy Oxygen Administration dated updated: 07/2017 documented in part, .When oxygen not in use, store oxygen tubing and nasal cannula or mask in separate, labeled plastic bag .Change all tubing and masks as per state protocol and label with date and initials .
On 4/22/21 at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
Reference:
1. Malignant neoplasm: The term malignancy refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. Malignant cells tend to have fast, uncontrolled growth and DO NOT die normally due to changes in their genetic makeup. Malignant cells that are resistant to treatment may return after all detectable traces of them have been removed or destroyed. This information was obtained from the website: https://medlineplus.gov/ency/article/002253.htm.
2. Tracheostomy: A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.
3. Ambu bag: A self-refilling bag-valve-mask unit with a 1-1.5 litre capacity, used for artificial respiration which, while suboptimal for the non-intubated patient, is effective for ventilating and oxygenating intubated patients, allowing both spontaneous and artificial respiration. This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/Ambu+bag
7. The facility staff failed to implement the comprehensive care plan for administration of oxygen to Resident #3.
Resident #3 was admitted to the facility with diagnoses that included but were not limited to heart failure (1) and cardiomyopathy (2).
Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/15/21 coded Resident #3 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O coded Resident #35 receiving oxygen while a resident at the facility.
The comprehensive care plan for Resident #3 dated 5/20/2015 documented in part, Resistive/non-compliant with treatment/care related to: refusing showers, getting out of bed says he has been in bed for years and not changing now, refusing meds, removes oxygen, refuses vital signs and therapy, refuses non-pharmacological interventions prior to PRN (as needed) medications, consistently in positions that can contribute to skin breakdown, stating he is going to remove life vest (3). Date Initiated: 05/20/2015. Revision on: 09/18/2020. It further documented, Cardiac disease related to Hypertension (high blood pressure), cardiomyopathy, CHF (congestive heart failure). Date Initiated: 03/17/2016. Under Interventions it documented in part, .O2 (oxygen) as ordered, encourage resident to keep oxygen tubing on and notify nurse if resident will not keep Oxygen on. Date Initiated: 09/19/2018. Revision on 03/24/2020 .and Administer medication per physician orders. Date Initiated: 03/17/2016 .
The physician orders for Resident #3 documented in part, .O2 @ (at) 2 liters per minute via nasal cannula every shift for supplemental oxygen. Order Date: 02/02/2021 .
On 4/20/21 at approximately 10:50 a.m., an interview was conducted with Resident #3 in their room. Resident #3 was observed lying in bed wearing a nasal cannula that was connected to an oxygen concentrator located to the right of Resident #3 beside their bed. The oxygen flow rate on the oxygen concentrator was observed set at 4 liters. Resident #3 stated that they wore the oxygen all the time at 4 liters. Resident #3 stated that they had problems with being able to feel the oxygen flow from the concentrator and the nurses would adjust it when needed. When asked if they ever adjusted the oxygen flow themselves Resident #3 laughed and stated, I do not have a right arm and I am bed ridden. I cannot reach the machine even if I wanted to. I have to call them to come and turn it up when I can't feel it.
On 4/20/21 at approximately 11:00 a.m., Resident #3 was observed leaving the facility on a stretcher wearing portable oxygen. The concentrator in Resident #3's room was observed off.
On 4/20/21 at approximately 1:30 p.m., Resident #3 was observed back in their room, the oxygen concentrator flowrate was observed set at 4 liters.
Additional observations on 4/21/21 at 9:10 a.m. and 3:30 p.m., revealed Resident #3's oxygen set at 4 liters.
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that the oxygen flow rate was checked at least every shift but should be checked each time the nurse enters the room. LPN #8 stated that the ball on the flowmeter of the concentrator should be centered on the line of the oxygen setting. LPN #8 stated that the purpose of the care plan was to make sure the residents needs were being met and provide the best care. LPN #8 stated that if the oxygen were not set on the prescribed rate that they were not following the care plan. On 4/22/21 at approximately 8:15 a.m., LPN #8 observed Resident #3's oxygen which was now set at 2 liters. Resident #3 stated that a nurse who he did not know came in that morning and changed the oxygen to 2 liters. Resident #3 stated that they could not feel any oxygen coming out of the cannula now and felt like they were not getting any oxygen. LPN #8 advised Resident #3 that they were contacting their physician to have the order changed to increase the oxygen.
The facility policy Oxygen Administration dated Updated: 07/2017, documented in part, .Application of Nasal cannula: .5. Set flow rate .
The manufacturer's instructions for use provided by the facility for the oxygen concentrator used by Resident #3 documented in part, .Warning. Do not change the L/min (liters per minute) setting on the flowmeter unless a change has been prescribed by your physician or therapist. Note: 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 line prescribed .
On 4/22/21 at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
On 4/22/21 at approximately 5:00 p.m., ASM #3, the quality consultant stated that staff reported to them that Resident #3 had adjusted the oxygen themselves after staff had set it this morning and they had been educated to not adjust the oxygen themselves and updated the care plan.
No further information was provided prior to exit.
Reference:
1. Heart failure: 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.
2. Cardiomyopathy -Disease in which the heart muscle becomes weakened, stretched, or has another structural problem. It often occurs when the heart cannot pump or function well. Most people with cardiomyopathy have heart failure. This information was obtained from the website: https://medlineplus.gov/ency/article/001105.htm.
3. Life vest: The LifeVest® wearable cardioverter defibrillator (WCD) is designed to protect patients at risk of sudden cardiac death (SCD), when a patient's condition is changing and permanent SCD risk has not been established. This information was obtained from the website: https://lifevest.[NAME].com/
2. For Resident #25, the facility (a) failed to develop a comprehensive care plan to address his urinary catheter and (b) failed to implement his care plan for a tracheostomy.
a. Resident #25 was admitted to the facility on [DATE] with diagnoses including epilepsy, COPD (chronic obstructive pulmonary disease) (1), and diabetes (2). The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/16/21, coded Resident #25 as moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). Resident #25 was coded as being totally dependent on the assistance of staff members for all activities of daily living. He was coded as having a Foley catheter (3) in place.
Resident #25 declined to be interviewed during the survey.
On 4/20/21 at 11:40 a.m., 4/20/21 at 12:47 p.m., 4/20/21 at 1:48 p.m., and 4/21/20 at 9:11 a.m., observation revealed Resident #25 lying on his back in bed. During each observation, a Foley catheter collection bag, contained in a privacy cover, was hanging on the bed frame. Observation revealed the catheter was draining light yellow urine.
A review of Resident #25's admission nursing assessment dated [DATE] revealed documentation confirming Resident #25 had a Foley catheter in place on admission.
A review of Resident #25's physicians' orders revealed the following order, dated 3/4/21, that documented, Foley catheter care q (each) shift. A second physicians order for Resident #25 dated 3/6/21, documented, Foley output every shift for monitoring purpose. There was no order for urinary output monitoring prior to 3/6/21.
Further review of Resident #25's clinical record revealed the following physician order, dated 3/24/21, Levofloxacin Tablet (5) 250 mg give one tablet via PEG (percutaneous endoscopic gastrostomy) tube (4) one time a day for UTI (urinary tract infection).
A review of Resident #25's comprehensive care plan dated 2/22/21, failed to evidence any information related to the resident's Foley catheter.
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed regarding the purpose of a comprehensive care plan. LPN #2 stated it is to make sure that all a resident's needs are met, and that the outcomes are accomplished. When asked if a resident's urinary catheter should be included in the comprehensive care plan, she stated it should.
On 4/21/21 at 3:08 p.m., CNA (certified nursing assistant) #3 was interviewed regarding the purpose of a resident's comprehensive care plan. CNA #3 stated it is to make sure all the needs of a resident are met. She added the staff should always be asking what they could do to improve. CNA #3 stated the staff should always be asking how the resident wants things done.
On 4/21/21 at 6:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and ASM #3, the quality consultant, were informed of these concerns.
On 4/22//21 at 1:41 p.m., LPN #5 was interviewed. She stated the purpose of a care plan is to make sure the things a resident needs to be cared for are all in place.
No further information was provided prior to exit.
REFERENCES
(1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.
(3) A urinary catheter (brand name Foley) is a tube placed in the body to drain and collect urine from the bladder. This information is taken from the website https://medlineplus.gov/ency/article/003981.htm.
(4) A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. PEG feeding tube insertion is done in part using a procedure called endoscopy. Feeding tubes are needed when you are unable to eat or drink. This may be due to stroke or other brain injury, problems with the esophagus, surgery of the head and neck, or other conditions. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000900.htm
(5) Levofloxacin (Levaquin) is used to treat certain infections such as pneumonia, and kidney, prostate (a male reproductive gland), and skin infections. Levofloxacin is also used to prevent anthrax (a serious infection that may be spread on purpose as part of a bioterror attack) in people who may have been exposed to anthrax germs in the air, and treat and prevent plague (a serious infection that may be spread on purpose as part of a bioterror attack. Levofloxacin may also be used to treat bronchitis, sinus infections, or urinary tract infections but should not be used for bronchitis and certain types of urinary tract infections if there are other treatment options available. Levofloxacin is in a class of antibiotics called fluoroquinolones. It works by killing bacteria that cause infections. This information is taken from the website https://medlineplus.gov/druginfo/meds/a697040.html.
(b) The failed staff failed to implement Resident #25's comprehensive care plan for tracheostomy care. The clinical record failed to evidence tracheostomy (6) care was provided to Resident #25, from 2/9/21 through 3/3/21.
On the following dates and times, 4/20/21 at 11:40 a.m., 4/20/21 at 12:47 p.m., 4/20/21 at 1:48 p.m., and 4/21/20 at 9:11 a.m., Resident #25 was observed lying on his back in bed. During each observation, Resident #25 was observed with a tracheostomy in place.
A review of Resident #25's comprehensive care plan dated 2/22/21 revealed, in part: Has/At risk for respiratory impairment related to COPD, tracheostomy .Trach [tracheostomy] care per protocol.
A review of Resident #25's admission nursing assessment dated [DATE] revealed documentation confirming Resident #25 had a tracheostomy in place on admission.
A review of Resident #25's physicians' orders revealed the following order, dated 3/4/21: Trach (tracheostomy) care Q (every) shift, every shift. There was no physician's order for trach care prior to 3/4[TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to review and/or revise Resident #44's comprehensive care plan to address a worsened pressure ulcer...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to review and/or revise Resident #44's comprehensive care plan to address a worsened pressure ulcer (1).
Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (2) and tracheostomy (3).
Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/12/21 coded Resident #44 as non-verbal and severely impaired of making daily decisions. Section G coded Resident #44 as totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependent on one staff member for eating and personal hygiene. Section M coded Resident #44 having one unstageable pressure ulcer.
The comprehensive care plan for Resident #44 dated 12/03/2020 documented in part, At risk for alteration in skin integrity related to impaired mobility. Date Initiated: 12/03/2020. Revision on 12/15/2020. The care plan further documented Open area to sacrum. Date Initiated: 01/29/2021. Created on: 01/29/2021. The care plan failed to document any revisions or updates since 1/29/2021.
The current physician orders for Resident #44 documented in part,
- Body Audit- daily one time a day for skin observation. Order Date: 03/08/2021.
- Sacral (4) wound- cleanse with normal saline, pack with anasep (wound cleanser) and 4x4's (gauze), skin prep (liquid film-forming dressing) peri wound (around the wound), cover with dry protective dressing, cover with transparent dressings. Change daily and prn (as needed) until resolved or no longer indicated. Order date: 03/29/2021.
The progress notes for Resident #44 documented in part the following:
- 1/13/2021 16:31 (4:31 p.m.) Note Text: Treatment order changed to sacrum area, cleanse with NS (normal saline) apply barrier cream cover with foam dressing q (every) day and prn. (as needed) Noted area to be 5cmx3cmx0.1cm (5 centimeters length by 3 centimeters width by 0.1 centimeters depth). Resident turned and re-positioned frequently.
- 1/20/2021 16:59 (4:59 p.m.) Late Entry: Note Text: Wound care to sacrum measuring 6.0cm x 3.0 cm x 0.1cm (6 centimeters length by 3 centimeters width by 0.1 centimeters depth). Resident turned and re-positioned frequently. Cleansed with NS apply barrier cream cover with foam dressing daily and prn.
- 2/11/2021 16:37 (4:37 p.m.) Note Text: L (left) buttock 3.8 cm x 6.0 cm (3.8 centimeters length by 6.0 centimeters width) area with 90% eschar (5) and 10% slough (6) with purulent (containing pus) drainage with foul odor noted. R (right) buttock area 1.5cm x 3cm (1.5 centimeter length by 3 cm width) with slough and purulent drainage noted.
- 2/24/2021 10:00 (10:00 a.m.) Note Text: Wound rounds completed. Wound bed is 40% granulation tissue (7), 30% slough, and 30% eschar, wound borders are irregular and unattached. A large amount of foul smelling, purulent drainage is noted on the dressing removed. Peri wound (around the wound) is normal skin tissue. Wound care provided according to Physician's orders. Dressing is changed daily and prn until resolved or no longer indicates use of Santyl (wound ointment to remove dead tissue) to wound bed.
- 3/3/2021 04:02 (4:02 a.m.) Note Text: Wound round completed on this Patient. Sacral wound measures (6.8 x 11.8 total affected area) (6.8 length by 11.8 width) 4.0 x 6.0 (center of wound) (4.0 length by 6.0 width) x depth immeasurable due to slough in wound bed, undermining (tunneling) of 3.0 @ 12 (at 12:00 position) is present, slough covering 90% of wound bed is thick, gray [sic],and adherent, 10 % granulation tissue present; borders are irregular and unattached, copious amount of purulent foul odor is present, peri wound is discolored. Continue with current treatment, change daily and prn (as needed) until resolved .
- 3/10/2021 06:47 (6:47 a.m.) Note Text: Wound round completed. Sacrum measures 5.8 x 11.8 x immeasurable (5.8 length by 11.8 width by depth), wound bed is 80% gray [sic] slough, 10% granulation tissue, and 10% skin, borders are irregular and unattached, there is a copious amount of foul smelling purulent drainage, peri wound is normal .
- 4/3/2021 19:43 (7:43 p.m.) Note Text: Wound care completed. Sacrum measures 5.8 x 5.7 x 4 x 3.5 (5.8 length by 5.7 width by 4 depth by 3.5 undermining). Unstageable. Wound bed is 80% gray [sic] slough, 10% granulation tissue, and 10% skin, borders are irregular and unattached, there is a copious amount of serosanguineous (8) drainage, peri wound is normal. Treatment as ordered by Dr (doctor). L (left) plantar area is resolved, continue to skin prep for prevention.
- 4/14/2021 13:54 (1:54 p.m.) Late Entry: Note Text: Wound round completed. Wound is progressing. Sacral wound total area affected is 7.7 x 8.9 (7.7 length by 8.9 width); 80% granulation, 20% skin; area that is packed (within first measurement) is 6.0 x 6.5 x 2.5 x 3.8 (6.0 length by 6.5 width by 2.5 depth by 3.8 undermining) @12 (at 12:00 position). Wound bed is fully granulated, borders are clean and irregular, there is a copious (large) amount of bloody drainage on dressing removed and new bleeding noted. Peri wound is normal also with some small areas of pink scar tissue. Treatment to be changed to Anasep liquid.
- 4/21/2021 12:58 (12:58 p.m.) Note Text: Sacral wound assessed. Wound bed 80% moist granulation tissue and 20% grey/ black slough with moderate amount serosanguineous drainage noted. Peri-wound macerated. Based on physical appearance and drainage, this will be classified as a stage IV (9) sacral wound. rp/ md (responsible party/nurse practitioner and or physician) aware.
- 4/22/2021 10:16 (10:16 a.m.) Note Text: Sacral wound measures 7.8 cm x 8.2 cm x 0.4 cm (7.8 centimeters length by 8.2 centimeters width by 0.4 centimeters depth). NP (nurse practitioner) notified. Order updated this am (morning) to bid (twice a day) due to drainage amount. rp (responsible party) aware.
On 4/21/21 at approximately 3:00 p.m., an observation was made of RN (registered nurse) #1 performing wound care to Resident #44's sacral wound. RN #1 stated that they had not seen Resident #44's wound prior to that day and could not speak to how the wound previously looked. RN #1 described Resident #44's wound as a Stage IV pressure ulcer and stated that they had recommended changing the treatment that was in place to the wound. Resident #44's wound was observed to be open, moist with a moderate amount of serosanguineous drainage.
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that care plans were in place to make sure the patients' needs were being met and to provide the best care. LPN #8 stated that care plans were revised and updated when a treatment was changed or there was a change in condition. LPN #8 stated that a worsened pressure ulcer should require a review of the care plan to ensure that all appropriate interventions were in place to promote wound healing.
The facility policy Interdisciplinary care planning dated updated 03/2018 documented in part, .The patient's care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also identifies the types and methods of care that the patient should receive . The policy further documented, .Once the care plan is developed, the staff must implement the interventions identified in the care plan. These may include, but is not limited to: administering medications and treatments .Evaluating means monitoring patients' progress toward their goals. Evaluation may result in: identifying factors affecting progress toward achieving goals, defining or redefining a patient's prognosis, adjusting treatment plans or interventions, or identifying when care objectives have been achieved and discharge, transfer, or a change in level of care is appropriate .
The facility policy Skin Practice Guide dated 2013 documented in part, .If a change in patient condition occurs, such as a deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents findings in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs . The policy further documented, .The approached for skin management are clear, specific and individualized for the patient's needs. Managing skin risk can be complex as there may be a combination of risk factors and causes. Regardless of the interventions that are put in place, a key factor to success is the timely review of the interventions as the patient's condition and needs change. Updates to the care plan are reflected on the Patient Information Worksheet, [NAME] and Task List .
On 4/22/21 at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
Reference:
1. Pressure ulcer are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000147.htm.
2. Intracerebral hemorrhage is bleeding in the brain caused by the breaking (rupture) of a blood vessel in the head. This information was obtained from the website: http://pacificschoolserver.org/med/ency/article/000796.htm.
3. Tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.
4. Sacral: The sacrum is a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/19464.htm
5. Eschar is dead tissue that falls off (sheds) from healthy skin. It is caused by a burn or cauterization (destroying tissue with heat or cold, or another method). This information was obtained from the website: https://medlineplus.gov/ency/article/002355.htm
6. Slough is soft, moist avascular tissue that adheres to the wound bed in strings or thick clumps; may be white, yellow, tan or green.
This information was obtained from the website: https://www.hopkinsmedicine.org/gec/series/wound_care.html#wound_assessment
7. Granulation: The wound starts to fill in with new tissue, called granulation tissue. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000741.htm
8. Serosanguineous means contains or relates to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood. This information was obtained from the website: https://medlineplus.gov/ency/article/002306.htm
9. Stage IV pressure ulcer is a pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website:https://medlineplus.gov/ency/patientinstructions/000740.htm.
2. The facility staff failed to review/ revise Resident #25's comprehensive care plan when he developed a urinary tract infection on 3/24/21.
Resident #25 was admitted to the facility on [DATE] with diagnoses including epilepsy, COPD (chronic obstructive pulmonary disease) (1), and diabetes (2). The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/16/21, coded Resident #25 was coded as moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). He was coded as being totally dependent on the assistance of staff members for all activities of daily living. Resident #25 was coded as having a Foley catheter (3) in place.
Resident #25 declined to be interviewed during the survey.
On the following dates and times: 4/20/21 at 11:40 a.m., 4/20/21 at 12:47 p.m., 4/20/21 at 1:48 p.m., and 4/21/20 at 9:11 a.m. observation revealed Resident #25 lying on his back in bed. During each observation, a Foley catheter collection bag, contained in a privacy cover, was hanging on the bed frame. The catheter was observed draining light yellow urine.
A review of Resident #25's admission nursing assessment dated [DATE] revealed documentation confirming Resident #25 had a Foley catheter in place on admission.
A review of Resident #25's physicians' orders revealed the following order, dated 3/6/21: Foley output every shift for monitoring purpose. There was no order for urinary output monitoring prior to 3/6/21.
A review of Resident #25's physicians' orders revealed the following order, dated 3/4/21: Foley catheter care q (each) shift.
Further review of Resident #25's clinical record revealed the following physician order, dated 3/24/21: Levofloxacin Tablet (5) 250 mg give one tablet via PEG (percutaneous endoscopic gastrostomy) tube (4) one time a day for UTI (urinary tract infection).
Review of Resident #25's comprehensive care plan dated 2/22/21 revealed no information related to the resident's Foley catheter, a urinary tract infection or the care and treatment prescribed.
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed, regarding the purpose of a care plan. LPN #2 stated it is to make sure that all a resident's needs are met, and that the outcomes are accomplished. When asked if a resident's urinary catheter should be included in the care plan, she stated it should. When asked if a resident's care plan should be updated if he develops an infection and is placed on an antibiotic, LPN #2 stated the care plan should be updated.
On 4/21/21 at 3:08 p.m., CNA (certified nursing assistant) #3 was interviewed, regarding the purpose of a resident's care plan, she stated it is to make sure all the needs of a resident are met. CNA #3 stated the staff should always be asking what they could do to improve. She stated the staff should always be asking how the resident wants things done.
On 4/21/21 at 6:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and ASM #3, the quality consultant, were informed of these concerns.
On 4/22//21 at 1:41 p.m., LPN #5 was interviewed. She stated the purpose of a care plan is to make sure the things a resident needs to be cared for are all in place. LPN #5 stated a resident's urinary tract infection and antibiotic order should be added to the care plan. She stated the nurse who receives the lab [laboratory] result or the antibiotic order is responsible for updating the care plan.
No further information was provided prior to exit.
REFERENCES
(1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.
(3) A urinary catheter (brand name Foley) is a tube placed in the body to drain and collect urine from the bladder. This information is taken from the website https://medlineplus.gov/ency/article/003981.htm.
(4) A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. PEG feeding tube insertion is done in part using a procedure called endoscopy. Feeding tubes are needed when you are unable to eat or drink. This may be due to stroke or other brain injury, problems with the esophagus, surgery of the head and neck, or other conditions. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000900.htm
(5) Levofloxacin (Levaquin) is used to treat certain infections such as pneumonia, and kidney, prostate (a male reproductive gland), and skin infections. Levofloxacin is also used to prevent anthrax (a serious infection that may be spread on purpose as part of a bioterror attack) in people who may have been exposed to anthrax germs in the air, and treat and prevent plague (a serious infection that may be spread on purpose as part of a bioterror attack. Levofloxacin may also be used to treat bronchitis, sinus infections, or urinary tract infections but should not be used for bronchitis and certain types of urinary tract infections if there are other treatment options available. Levofloxacin is in a class of antibiotics called fluoroquinolones. It works by killing bacteria that cause infections. This information is taken from the website https://medlineplus.gov/druginfo/meds/a697040.html.
3. The facility staff failed to review and revise Resident #19's comprehensive care plan when the resident developed a pressure injury on 2/10/21.
Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to end stage renal disease, diabetes and muscle weakness. Resident #19's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/7/21 coded the resident as being cognitively intact.
Review of Resident #19's clinical record revealed the resident developed a pressure injury (1) measuring 0.3-0.6 square centimeters on the left great toe on 2/10/21. Review of Resident #19's comprehensive care plan dated 2/1/21 failed to reveal the care plan had been reviewed and revised when the resident developed the pressure injury on 2/10/21.
On 4/22/21 at 2:07 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the purpose of the care plan is to make sure things that patients need are in place to care for them properly. LPN #5 stated care plans should absolutely be reviewed and revised when a resident develops a pressure injury.
On 4/22/21 at approximately 5:45 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
No further information was presented prior to exit.
Reference:
(1) A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. This information is taken from the National Pressure Ulcer Advisory Panel website https://cdn.ymaws.com/npiap.com/resource/resmgr/2014_guideline.pdf
Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review and revise a comprehensive care plan for 4 of 25 residents in the survey sample, (Residents #60, #25, #19, and #44).
The facility staff failed to review and revise the comprehensive care plans for Resident #60 and Resident #25 to address urinary tract infections and the care and treatment prescribed, and failed to review and revise Resident #44's comprehensive care plan to address a worsening of a pressure ulcer.
2. The facility staff failed to review/ revise Resident #25's comprehensive care plan when he developed a urinary tract infection on 3/24/21.
3. The facility staff failed to review and revise Resident #19's comprehensive care plan when the resident developed a pressure injury on 2/10/21.
4. The facility staff failed to review and/or revise Resident #44's comprehensive care plan to address a worsened pressure ulcer (1).
The findings include:
1. Resident #60 was admitted to the facility on [DATE] with the diagnoses of but not limited to Moyamoya disease, quadriplegia, seizures, high blood pressure, chronic kidney disease, depression, cerebrovascular disease, and human immunodeficiency virus. The most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/29/21, coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating, which the resident was coded as requiring extensive assistance.
A review of the clinical record revealed a physician's order dated 4/16/21 for Macrobid Capsule (1) 100 MG (milligrams) (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for Uti (urinary tract infection) for 7 Days.
A nurse practitioner progress note dated 4/16/21 at 6:10 PM documented, .being seen today with complaints of new onset moderate pain with urination that has been present for 5 days. Associated symptoms include frequency. Exacerbating factors include urinary incontinent. Current treatment includes increased fluid intake and Vit C (Vitamin C) (2). UA C&S (Urinalysis with culture and sensitivity) (3) obtained on 4/12/21 reporting positive results.
Resident #60's comprehensive care plan dated 7/8/20, documented, Urinary Incontinence which included an intervention dated 7/8/20 for Report S&S (signs and symptoms) of UTI such as flank pain, c/o (complaints of) burning/pain, fever, hematuria, change in mental status, etc. Further review of this care plan failed to reveal any evidence of being updated to include the above treatment for an active urinary tract infection. Further review of the entire comprehensive care plan also failed to reveal any evidence of being updated for the above treatment of an active urinary tract infection.
On 4/21/21 at 3:07 PM in an interview with LPN #2 (Licensed Practical Nurse), she stated that the care plan should be updated to include the antibiotic treatment for a new/current infection. LPN #2 stated that change in conditions should be added to the care plan.
A review of the facility policy, Interdisciplinary Care Planning documented, As the care plan is implemented, members of the interdisciplinary team need to evaluate whether the interventions are effective or whether the care plan needs to be revised. Evaluating the effectiveness of care plan interventions will help the disciplinary team modify the care plan as needed to help the patient reach their highest practicable level of well-being.
On 4/21/21 at 6:00 PM at the end of day meeting, ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey.
References:
(1) Macrobid - is used to treat urinary tract infections.
Information obtained from https://medlineplus.gov/druginfo/meds/a682291.html
(2) Vitamin C - Vitamin C is an antioxidant. It is important for your skin, bones, and connective tissue. It promotes healing and helps the body absorb iron.
Information obtained from https://medlineplus.gov/vitaminc.html
(3) UA C&S - A urinalysis is a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes. A urine culture is a lab test to check for bacteria or other germs in a urine sample. Sensitivity analysis determines the effectiveness of antibiotics against microorganisms (germs) such as bacteria that have been isolated from cultures.
Information obtained from https://medlineplus.gov/urinalysis.html and https://medlineplus.gov/ency/article/003751.htm and https://medlineplus.gov/ency/article/003741.htm
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hem...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (4) and tracheostomy (5).
Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of [DATE] coded Resident #44 as being non-verbal and severely impaired of making daily decisions. Section G documented Resident #44 as being totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependent on one staff member for eating and personal hygiene. Section M documented Resident #44 having one unstageable pressure injury.
On [DATE] at approximately 10:45 a.m., an observation was made of Resident #44 in their room. Resident #44 did not respond to verbal prompting. Resident #44 was observed lying in their bed with a pressure-relieving mattress.
On [DATE] at approximately 3:00 p.m., an observation was made of RN (registered nurse) #1 performing wound care to Resident #44's sacral wound. RN #1 stated that they had not seen Resident #44's wound prior to that day and could not speak to how the wound previously looked. RN #1 described Resident #44's wound as a Stage IV (6) pressure ulcer and stated that they had recommended changing the treatment that was in place to the wound. Resident #44's wound was observed to be open, moist with a moderate amount of serosanguineous (7) drainage.
A review of Resident #44's Braden Scale Assessment (8) for risk of developing pressure injuries dated [DATE] revealed that they were at very high risk, having scored nine.
The progress notes for Resident #44 documented, [DATE] 16:31 (4:31 p.m.) Note Text: Treatment order changed to sacrum area, cleanse with NS (normal saline) apply barrier cream cover with foam dressing q (every) day and prn. Noted area to be 5cmx3cmx0.1cm (5 centimeters length by 3 centimeters width by 0.1 centimeters depth). Resident turned and re-positioned frequently.
Review of Resident #44's wound documentation failed to evidence any documentation of a PUSH tool assessment of the sacral pressure injury being completed on [DATE].
The progress notes for Resident #44 documented, [DATE] 16:59 (4:59 p.m.) Late Entry: Note Text: Wound care to sacrum measuring 6.0cm x 3.0 cm x 0.1cm (6 centimeters length by 3 centimeters width by 0.1 centimeters depth). Resident turned and re-positioned frequently. Cleansed with NS apply barrier cream cover with foam dressing daily and prn.
Review of Resident #44's wound documentation failed to evidence any documentation of a PUSH tool assessment of the sacral pressure injury being completed on [DATE].
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 15.
The progress notes for Resident #44 failed to evidence documentation of any assessment such as measurements, description of the wound, completed for the sacral pressure injury on [DATE].
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 15.
The progress notes for Resident #44 failed to evidence documentation of any assessment such as measurements, description of the wound completed on the sacral pressure injury on [DATE].
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 15.
A progress notes for Resident #44 documented, [DATE] 16:37 (4:37 p.m.) Note Text: L (left) buttock 3.8 cm x 6.0 cm (3.8 centimeters length by 6.0 centimeters width) area with 90% eschar (9) and 10% slough (10) with purulent (containing pus) drainage with foul odor noted. R (right) buttock area 1.5cm x 3cm (1.5 centimeter length by 3 cm width) with slough and purulent drainage noted.
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 17.
The progress notes for Resident #44 failed to evidence documentation of any assessment such as measurements, description of the wound completed for the sacral pressure injury on [DATE].
The progress notes for Resident #44 documented, [DATE] 10:00 (10:00 a.m.) Note Text: Wound rounds completed. Wound bed is 40% granulation tissue (11), 30% slough, and 30% eschar, wound borders are irregular and unattached. A large amount of foul smelling, purulent drainage is noted on the dressing removed. Peri wound (around the wound) is normal skin tissue. Wound care provided according to Physician's orders. Dressing is changed daily and prn until resolved or no longer indicates use of Santyl (wound ointment to remove dead tissue) to wound bed.
Review of Resident #44's wound documentation failed to evidence any documentation of a PUSH tool assessment of the sacral pressure injury being completed on [DATE].
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 16.
The progress notes for Resident #44 documented, [DATE] 04:02 (4:02 a.m.) Note Text: Wound round completed on this Patient. Sacral wound measures (6.8 x 11.8 total affected area) (6.8 length by 11.8 width) 4.0 x 6.0 (center of wound) (4.0 length by 6.0 width) x depth immeasurable due to slough in wound bed, undermining (tunneling) of 3.0 @ 12 (at 12:00 position) is present, slough covering 90% of wound bed is thick, gray [sic], and adherent, 10 % granulation tissue present; borders are irregular and unattached, copious amount of purulent foul odor is present, peri wound is discolored. Continue with current treatment, change daily and prn (as needed) until resolved .
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 16.
The progress notes for Resident #44 documented, [DATE] 06:47 (6:47 a.m.) Note Text: Wound round completed. Sacrum measures 5.8 x 11.8 x immeasurable (5.8 length by 11.8 width by depth), wound bed is 80% gray [sic] slough, 10% granulation tissue, and 10% skin, borders are irregular and unattached, there is a copious amount of foul smelling purulent drainage, peri wound is normal .
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 16.
The progress notes for Resident #44 documented, [DATE] 19:43 (7:43 p.m.) Note Text: Wound care completed. Sacrum measures 5.8 x 5.7 x 4 x 3.5 (5.8 length by 5.7 width by 4 depth by 3.5 undermining). Unstageable. Wound bed is 80% gray slough, 10% granulation tissue, and 10% skin, borders are irregular and unattached, there is a copious amount of serosanguineous drainage, peri wound is normal. Treatment as ordered by Dr (doctor) .
The PUSH tool for Resident #44 documented an assessment of the sacral pressure injury completed on [DATE] with a score of 15.
The progress notes for Resident #44 documented, [DATE] 13:54 (1:54 p.m.) Late Entry: Note Text: Wound round completed. Wound is progressing. Sacral wound total area affected is 7.7 x 8.9 (7.7 length by 8.9 width); 80% granulation, 20% skin; area that is packed (within first measurement) is 6.0 x 6.5 x 2.5 x 3.8 (6.0 length by 6.5 width by 2.5 depth by 3.8 undermining) @12 (at 12:00 position). Wound bed is fully granulated, borders are clean and irregular, there is a copious (large) amount of bloody drainage on dressing removed and new bleeding noted. Peri wound is normal also with some small areas of pink scar tissue. Treatment to be changed to Anasep liquid.
The progress notes for Resident #44 documented, [DATE] 12:58 (12:58 p.m.) Note Text: Sacral wound assessed. Wound bed 80% moist granulation tissue and 20% grey/ black slough with moderate amount serosanguineous drainage noted. Peri-wound macerated. Based on physical appearance and drainage, this will be classified as a stage IV sacral wound. RP/md (responsible party/nurse practitioner) aware.
The progress notes for Resident #44 documented, [DATE] 10:16 (10:16 a.m.) Note Text: Sacral wound measures 7.8 cm x 8.2 cm x 0.4 cm (7.8 centimeters length by 8.2 centimeters width by 0.4 centimeters depth). NP (nurse practitioner) notified. Order updated this am (morning) to bid (twice a day) due to drainage amount. rp (responsible party) aware.
Review of Resident #44's clinical record failed to evidence documentation of PUSH tool assessments of the residents sacral pressure injury on [DATE], [DATE], [DATE] and the timeframe between [DATE] and [DATE], (approximately 24 day) and between [DATE] and [DATE], (approximately 11 days).
Resident #44's progress notes failed to document any descriptions of the wound or measurements of the pressure injury completed on [DATE], [DATE], [DATE], between [DATE] and [DATE] and between [DATE] and [DATE].
The comprehensive care plan for Resident #44 dated [DATE] documented in part, At risk for alteration in skin integrity related to impaired mobility. Date Initiated: [DATE]. Revision on [DATE]. The care plan further documented Open area to sacrum. Date Initiated: [DATE]. Created on: [DATE]. The care plans failed to document any revisions or updates after [DATE].
On [DATE] at 11:53, ASM (administrative staff member) #3, the quality consultant, ASM #1, the administrator, RN (registered nurse) #1, and ASM #2, the DON (director of nursing) were interviewed regarding the facility's process for assessing, monitoring, and treating pressure injuries. RN #1 stated she was not the wound nurse for this facility, but that she is the wound nurse for a sister facility. She stated she had been asked to come to the facility that morning to help out. ASM #1 stated the wound nurse position at this facility is currently posted, and the facility is actively recruiting candidates to fill the position. RN #1 stated she had not assessed any of the facility wounds until that morning. ASM #1 also stated there was no wound specialist who currently makes rounds and treats residents at the facility.
ASM #3 stated the process for a resident on admission is to identify if the resident has any skin integrity issues and to identify the resident's risk for developing a pressure injury. These are done by a Braden scale (to determine risk) and by the admission nursing assessment. If the resident is admitted with pressure injury, the physician is contacted for treatment orders. Additionally, per facility policy, a pressure injury assessment is completed for the resident on admission. She stated if a resident has a pressure injury, he/she is seen weekly during IDT (interdisciplinary team) wound rounds. When asked who composes the IDT team, ASM #3 stated the IDT team includes the DON, unit manager, and wound nurse. ASM #3 stated, They go in every week and look at every wound. She stated someone on the team writes a comprehensive progress note with measurements and a description of the wound. When asked if wound staging is included in the IDT wound rounds each week, ASM #3 stated PUSH tools and staging are used to monitor a wounds progression, healing, or decline. She stated a PUSH tool calculates the size of a wound (surface area) as well as the amount of any material that is coming from the wound (exudate). The PUSH tool also tracks the type of tissue in a wound bed, and uses all of those values to convert the wound to a numerical score. ASM #3 stated this gives a quick look of how the wound is doing. She stated the facility protocol is to develop a PUSH tool for every wound. ASM #3 stated a pressure injury should be assessed weekly. She stated if there is a change in the status of the wound, or something is abnormal, then that should also be documented in a progress note. She stated all pressure injuries and pressure injury treatments should be documented on the resident's care plan. She stated the process is the same for a resident who develops a pressure injury after admission.
When asked about the lack of evidence of staging for all wounds, ASM #3 stated there is a deficit in staging in the documentation. She stated weekly wound rounds, PUSH tools, and descriptions could still monitor pressure injuries. A request was made to ASM #3 for any additional documentation for Resident #44's sacral wound. ASM #3 was informed of the concern that Resident #44's clinical record lapsed documentation assessments of the sacral pressure injury other than the progress notes in the clinical record. ASM #3 stated they would provide the PUSH tool assessments for Resident #44's sacral wound. ASM #3 was also informed of the concern that Resident #44's progress notes failed to document any descriptions of the wound or measurements of the pressure injury completed between [DATE] and [DATE] and between [DATE] and [DATE].
On [DATE] at approximately 3:45 p.m., a telephone interview was conducted with ASM #5, medical doctor. ASM #5 stated that long-term care residents received in house wound care. ASM #5 stated that the nurses would assess the wound and notify them. ASM #5 stated that they would assess a pressure ulcer if needed but relied heavily on the wound team for assessments and communication on wound healing and decline. ASM #5 stated that the nurse notified them if a wound appeared infected or needed culture and when the treatment was not working. ASM #5 stated that they were in the facility twice a week and one day was dedicated to new admissions. ASM #5 stated that they mostly rely on the wound care team to assess and inform them of the condition of wounds unless they were requested to assess it. ASM #5 stated that there should be pressure ulcer staging and that most of time there is a diameter and a depth. ASM #5 stated that without staging it was impossible to tell if the wound was getting better or not. ASM #5 stated that residents have their treatments completed prior to them arriving at the facility and they assess the dressing in place over the wound but do not remove the dressing. ASM #5 stated that without staging it was hard to assess a pressure ulcer.
On [DATE] at approximately 11:20 a.m., a request was made to ASM #1, ASM #2, ASM #3 and ASM #4 for any additional documentation of assessments including PUSH tool assessments of Resident #44's pressure ulcer from the date of discovery through the present. ASM #3 was informed of the concern that Resident #44's clinical record failed to evidence documentation of PUSH tool assessments of the sacral pressure injury on [DATE], [DATE], [DATE] and the timeframe between [DATE] and [DATE], (approximately 24 day) and between [DATE] and [DATE], (approximately 11 days). ASM #3 was also informed of the concern that Resident #44's progress notes failed to document any descriptions of the wound or measurements of the pressure injury completed on [DATE], [DATE], [DATE], between [DATE] and [DATE] and between [DATE] and [DATE].
On [DATE] at approximately 3:23 p.m., ASM #3, the quality consultant provided a copy of the pressure ulcer scale for healing (PUSH) document with assessments dated 1/27, 2/3, 2/10, 2/17, 3/3, 3/10, 4/3, 4/14, skin notes for the [DATE] wound care and assessment, an order audit report for the [DATE] sacral wound order by LPN (licensed practical nurse) #7, and a progress note dated [DATE] which documented a change in treatment to the sacral wound. ASM #3 stated that they had reviewed Resident #44's clinical record and the PUSH document and there were gaps in the documentation but according to the PUSH tool, the wound had improved during the times when the documentation was lapsed. ASM #3 stated that the PUSH tool showed the progression of the wound and even if the measurements of the wound got larger, the wound bed may have become visible during the treatment process. ASM #3 stated that the order for treatment for Resident #44's sacral wound dated [DATE] was a prophylactic treatment and that Resident #44 did not have an open area until [DATE].
The facility skin practice guide documented in part, .The wound management team re-evaluates pressure ulcers and complex wounds weekly and other types of wounds as clinically indicated. Documentation of findings is completed on the PUSH Tool or Skin Alteration Record, whichever is appropriate for the type of wound and a progress note .
On [DATE] at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
Reference:
1. PUSH Tool
The Pressure Ulcer Scale for Healing (PUSH Tool) was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time .The NPUAP recommends use of the PUSH Tool at regular intervals. The AHCPR Treatment Guideline recommends assessments be performed at least weekly and if the condition of the patient or of the wound deteriorates. The PRESSURE ULCER HEALING CHART (which is attached to the PUSH Tool) will allow you to graph PUSH Tool scores over time for each ulcer. You should be able to tell at a glance whether the ulcer is healing, remains unchanged, or is deteriorating.
The PUSH Tool is designed to monitor the three critical parameters that are the most indicative of healing. In developing specific treatment plans, you will need to assess additional parameters (e.g., foul odor, color of exudate, undermining, and tunneling). Any increase in the PUSH Tool score (indicating wound deterioration) requires a more complete assessment of the ulcer and the patient's overall condition. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/push_tool_information_form.pdf.
2. Sacral
The sacrum is a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis. The sacrum forms the posterior pelvic wall, strengthens, and stabilizes the pelvis. Joined at the very end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx or tail bone. The coccyx provides slight support for the pelvic organs but actually is a bone of little use. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/19464.htm
3. Pressure injury
A pressure injury is localized damage to the skin and underlying soft tissue usually over a
bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or
prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities
and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.
4. Intracerebral hemorrhage
Bleeding in the brain caused by the breaking (rupture) of a blood vessel in the head. This information was obtained from the website: http://pacificschoolserver.org/med/ency/article/000796.htm.
5. Tracheostomy
A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube . This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.
6. Stage IV pressure ulcer
A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm.
7. Serosanguineous
Serosanguineous means contains or relates to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood. This information was obtained from the website: https://medlineplus.gov/ency/article/002306.htm
8. Braden Assessment
The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. This information was obtained from the website: https://pubmed.ncbi.nlm.nih.gov/3299278/
9. Eschar
Eschar is dead tissue that falls off (sheds) from healthy skin. It is caused by a burn or cauterization (destroying tissue with heat or cold, or another method). This information was obtained from the website: https://medlineplus.gov/ency/article/002355.htm
10. Slough
Soft, moist avascular tissue that adheres to the wound bed in strings or thick clumps; may be white, yellow, tan or green.
This information was obtained from the website: https://www.hopkinsmedicine.org/gec/series/wound_care.html#wound_assessment
11. Granulation
The wound starts to fill in with new tissue, called granulation tissue. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000741.htm
Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent and promote healing of a pressure injury for two of 25 residents in the survey sample, Residents #25 and #44.
1. The facility staff failed to ensure ongoing assessments to include measurements, descriptions and the completion of a PUSH tool for the Resident #25's right lateral fifth toe pressure injury. Resident #25's clinical record revealed a PUSH tool (8) was completed for each of the resident's pressure injuries except for the right lateral foot, fifth toe pressure injury. In addition the facility staff failed to evidence any measurements or description of the right lateral foot, fifth toe pressure injury, from [DATE] through [DATE] and on [DATE].
2. For Resident #44, the facility staff failed to ensure ongoing assessments to include measurements, descriptions and completion of a PUSH tool (1) assessment for the resident's sacral (2) pressure injury (3). Resident #44's clinical record failed to evidence a PUSH tool assessment of the sacral pressure injury on [DATE], [DATE], [DATE] and the timeframe between [DATE] and [DATE] and between [DATE] and [DATE].
The findings include:
1. Resident #25 was admitted to the facility on [DATE] with diagnoses including epilepsy, COPD (chronic obstructive pulmonary disease) (2), and diabetes (3). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of [DATE], Resident #25 was coded as moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). He was coded as being totally dependent on the assistance of staff members for all activities of daily living. He was coded as having one pressure injury at a stage 1 (4), and one pressure injury at a stage 2 (5). Both pressure injuries were coded as present on admission.
Resident #25 declined to be interviewed during the survey.
On the following dates and times, [DATE] at 11:40 a.m., [DATE] at 12:47 p.m., [DATE] at 1:48 p.m., and [DATE] at 9:11 a.m., Resident #25 was observed lying on his back in bed. During each observation, Resident #25 was observed wearing pressure-relieving boots on both feet, and resting on a pressure-relieving mattress.
A review of Resident #25's admission nursing assessment dated [DATE] revealed documentation of the following skin integrity issues: discolored area to right inner ankle, small open area with discoloration to peri wound (area surrounding the wound) on right inner ankle, left heel, right heel.
A review of Resident #21's Braden Scale Assessment for risk of developing pressure injuries dated [DATE] revealed that he was at high risk, having scored 11.
A review of Resident #21's clinical record failed to reveal any measurements of his pressure ulcers on admission.
Further review of Resident #25's clinical record failed to reveal a PUSH tool (7) assessment the right lateral foot, fifth toe pressure injury.
Further review of Resident #21's clinical record revealed the following documentation regarding his fifth toe pressure injury:
- [DATE]: Right lateral 5th toe 1.5 cm x 1.7 cm dark red/purple area with no drainage.
- [DATE]: Resident's skin check completed. No bruising, skin tears, or wounds were noted .will continue to monitor for changes in the skin's integrity.
- [DATE]: Wound rounds completed on Patient. R (right) 5th toe measures 0.8 x 0.5, skin alteration is dark in color, no drainage noted, peri wound is dry flaky skin. Treatments to areas per Dr (doctor) orders are provided daily and prn (as needed) until resolved.
- [DATE]: Wound rounds completed. R 5th toe has irregular borders, neither area has drainage, and both are surrounded by pink scar tissue. All treatments provided as ordered.
- [DATE]: R lateral foot near 5th toe is 1.9 x 0.9 dark brown/black intact skin with no drainage. Follow all treatment orders.
- [DATE]: Wound round completed. There were no documented assessment, no description or measurements of the R 5th toe pressure ulcer on [DATE].
- There was no documented assessment, description or measurements of the R 5th toe pressure ulcer between [DATE] and [DATE], (a sixteen day period).
- [DATE]: Late entry for wound/s. R lateral foot wound near toes is beefy red and 100% granulated, measures 1.7 x 1.8 x 0.2 with irregular borders, moderate serosanguineous drainage noted, peri wound is normal . Continue all treatments per orders
- [DATE]: Wound care completed. There were no measurements or description of the R 5th toe pressure injury.
- [DATE]: Wound round completed. R lateral foot near 5th toe, wound bed is fully granulated, area measures 1.5 x 1.5 x 0.2, there is a moderate amount of serosanguineous drainage on dressing removed, peri wound is normal, treatment to be changed to puracol plus . Resident has pressure relieving boots on while in bed as tolerated.
- [DATE]: Right lateral foot wound is 74% epithelial tissue and 25% moist granulation tissue. MD (medical doctor) notified of wound changes. New order obtained and followed through. Rp (responsible party) (sic) aware
- [DATE]: .Right lat (lateral) foot distal aspect measures 2 cm x 2.2 cm x <0. (less than) 1 cm. rp/ md aware .Clarification; Wound is 75% epithelial tissue and 25% moist protruding granular tissue with scant seosanguinous (sic) drainage without odor noted. Protruding tissue is soft and boggy to palpation. This will be classified as a healing unstageable pressure ulcer
A review of Resident #25's comprehensive care plan, dated [DATE] and updated [DATE], revealed, in part: At risk for alteration in skin integrity related to impaired mobility, DTI (deep tissue injury) (6) to right lateral foot near 5th digit .administer treatment per physician order .open area to left heel .administer treatment per physician orders.
On [DATE] at 11:53, ASM (administrative staff member) #3, the quality consultant, ASM #1, the administrator, RN (registered nurse) #1, and ASM #2, the DON (director of nursing) were interviewed regarding the facility's process for assessing, monitoring, and treating pressure injuries. RN #1 stated she was not the wound nurse for this facility, but that she is the wound nurse for a sister facility. She stated she had been asked to come to the facility that morning to help out. ASM #1 stated the wound nurse position at this facility is currently posted, and the facility is actively recruiting candidates to fill the position. RN #1 stated she had not assessed any of the facility wounds until that morning. ASM #1 also stated there was no wound specialist who currently makes rounds and treats residents at the facility.
ASM #3 stated the process for a resident on admission is to identify if the resident has any skin integrity issues and to identify the resident's risk for developing a pressure injury. These are done by a Braden scale (to determine risk) and by the admission nursing assessment. If the resident is admitted with pressure injury, the physician is contacted for treatment orders. Additionally, per facility policy, a pressure injury assessment is completed for the resident on admission. She stated if a resident has a pressure injury, he/she is seen weekly during IDT (interdisciplinary team) wound rounds. When asked who composes the IDT team, ASM #3 stated the IDT team includes the DON, unit manager, and wound nurse. ASM #3 stated, They go in every week and look at every wound. She stated someone on the team writes a comprehensive progress note with measurements and a description of the wound. When asked if wound staging is included in the IDT wound rounds each week, ASM #3 stated PUSH tools and staging are used to monitor a wounds progression, healing, or decline. She stated a PUSH tool calculates the size of a wound (surface area) as well as the amount of any material that is coming from the wound (exudate). The PUSH tool also tracks the type of tissue in a wound bed, and uses all of those values to convert the wound to a numerical score. ASM #3 stated this gives a quick look of how the wound is doing. She stated the facility protocol is to develop a PUSH tool for every wound. ASM #3 stated a pressure injury should be assessed weekly. She stated if there is a change in the status of the wound, or something is abnormal, then that should also be documented in a progress note. She stated all pressure injuries and pressure injury treatments should be documented on the resident's care plan. She stated the process is the same for a resident who develops a pressure injury after admission.
The staff members present for this interview were informed that a PUSH tool for Resident #25's right lateral foot/fifth toe could not be located.
When asked about the lack of evidence of staging for all wounds, ASM #3 stated there is a deficit in staging in the documentation. She stated pressure injuries can still be monitored by weekly wound rounds, PUSH tools, and descriptions.
On [DATE] at 3:45 p.m., ASM #5, a physician, was interviewed. ASM #5 was asked about her role in assessing, monitoring, and treating pressure injuries. She stated nursing usually takes care of it. She stated if there is any concern at all, the nurses notify her. She stated she is in the building at least once a week, and is available to see residents. ASM #5 stated the facility now has an in-house wound nurse, and the wound nurse or floor nurses do wound assessments. She stated the nurses
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**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...
Read full inspector narrative →
**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 failed to provide services related to a urinary catheter for one of 25 current residents in the survey sample, Resident #25. The facility failed to monitor and record urinary output amounts on multiple dates since the resident's admission on [DATE]. The facility failed to evidence Foley catheter care on multiple dates since the resident's admission on [DATE].
The findings include:
Resident #25 was admitted to the facility on [DATE] with diagnoses including epilepsy, COPD (chronic obstructive pulmonary disease) (1), and diabetes (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/16/21, Resident #25 was coded as being moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). Resident #25 was coded as being totally dependent on the assistance of staff members for all activities of daily living. He was coded as having a Foley catheter (3) in place.
Resident #25 declined to be interviewed during the survey.
On the following dates and times, 4/20/21 at 11:40 a.m., 4/20/21 at 12:47 p.m., 4/20/21 at 1:48 p.m., and 4/21/20 at 9:11 a.m., Resident #25 was observed lying on his back in bed. At all observations, a Foley catheter collection bag, contained in a privacy cover, was hanging on the bed frame. The catheter was observed draining light yellow urine.
A review of Resident #25's admission nursing assessment dated [DATE] revealed documentation confirming Resident #25 had a Foley catheter in place on admission.
A review of Resident #25's physicians' orders revealed the following order, dated 3/6/21: Foley output every shift for monitoring purpose. There was no order for urinary output monitoring prior to 3/6/21.
A review of Resident #25's TARs (treatment administration records) revealed no documentation for urinary output on the following dates and times: 3/9/21 night shift, 3/11/21 day shift, 3/13/21 day shift, 3/23/21 day shift, 3/25/21 day shift, 3/27/21 day and evening shifts, 3/28/21 evening and night shifts, 3/30/21 evening shift, 4/2/21 evening shift, 4/4/21 day and evening shifts, 4/7/21 day shift, 4/10/21 day shift, 4/11/21 day shift, 4/17/21 day shift.
A review of Resident #25's physicians' orders revealed the following order, dated 3/4/21: Foley catheter care q (every) shift.
A review of Resident #25's TARs revealed no documentation related to Foley catheter care for any shift between 2/9/21 and 3/4/21.
Further review of Resident #25's clinical record revealed the following physician order, dated 3/24/21: Levofloxacin Tablet (5) 250 mg give one tablet via PEG (percutaneous endoscopic gastrostomy) tube (4) one time a day for UTI (urinary tract infection).
A review of Resident #25's comprehensive care plan dated 2/22/21 revealed no information related to the resident's Foley catheter.
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked if she takes care of Resident #25 regularly, she stated she does. When asked if it is important to monitor Resident #25's urine output, she stated it is important in order to make sure the resident is not retaining fluid. LPN #2 stated the resident receives tube feedings, and the nurses need to make sure he is putting out a moderate amount of fluid. She stated she checks on the resident periodically throughout her shift to make sure the resident's Foley catheter is draining, and the CNAs (certified nursing assistants) give the total amount of urine output at the end of each shift. When asked if it is possible to monitor a resident's urinary output across days if there is no specific amount of output documented in the record, LPN #2 stated there is not.
On 4/21/21 at 3:08 p.m., CNA #3 was interviewed. When asked about the process used for tracking a resident's urine output, CNA #3 stated she totals the output at the end of the shift when she empties the urine collection bag, and she reports the amount to the nurse.
On 4/22/21 at 5:17 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and ASM #3, the quality consultant, were informed of these concerns. Policies related to Foley catheter care and monitoring urinary output were requested.
On 4/23/21 at 10:08 a.m., ASM #3 stated there is no evidence Foley catheter care was provided to Resident #25 prior to 3/6/21. ASM #3 stated the facility's standard is not to monitory urinary output for a resident who has a Foley catheter unless a physician orders it. She stated the facility does not have a policy related to urinary output.
A review of the facility policy, Catheter Care: Indwelling Catheter, revealed, in part, the following: Purpose: To provide hygiene for patients with indwelling catheters.
No further information was provided prior to exit.
REFERENCES
(1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.
(3) A urinary catheter (brand name Foley) is a tube placed in the body to drain and collect urine from the bladder. This information is taken from the website https://medlineplus.gov/ency/article/003981.htm.
(4) A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. PEG feeding tube insertion is done in part using a procedure called endoscopy. Feeding tubes are needed when you are unable to eat or drink. This may be due to stroke or other brain injury, problems with the esophagus, surgery of the head and neck, or other conditions. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000900.htm
(5) Levofloxacin (Levaquin) is used to treat certain infections such as pneumonia, and kidney, prostate (a male reproductive gland), and skin infections. Levofloxacin is also used to prevent anthrax (a serious infection that may be spread on purpose as part of a bioterror attack) in people who may have been exposed to anthrax germs in the air, and treat and prevent plague (a serious infection that may be spread on purpose as part of a bioterror attack. Levofloxacin may also be used to treat bronchitis, sinus infections, or urinary tract infections but should not be used for bronchitis and certain types of urinary tract infections if there are other treatment options available. Levofloxacin is in a class of antibiotics called fluoroquinolones. It works by killing bacteria that cause infections. This information is taken from the website https://medlineplus.gov/druginfo/meds/a697040.html.
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** 6. The facility failed to provide oxygen at the physician prescribed flow rate for Resident #24 and failed to ensure tracheostom...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The facility failed to provide oxygen at the physician prescribed flow rate for Resident #24 and failed to ensure tracheostomy care was provided as ordered by the physician on 4/12/21, 4/13/21 and 4/16/21 day shift and failed to ensure an ambu bag was present at Resident #24's bedside per the facility policy.
Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3).
Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS Section G- Functional Status: coded the resident as dependent with bed mobility, transfers, dressing, eating, personal hygiene and bathing; walking and locomotion did not occur. A review of MDS Section O- Special treatments, procedures and programs: coded the resident as tracheostomy 'yes' and oxygen therapy 'yes'.
During initial resident observation on 4/20/21 at 10:35 AM, observation revealed Resident #24 with tracheostomy [trach] and receiving O2 via concentrator. Resident #24's O2 (oxygen) setting on the oxygen concentrator flowmeter was observed at 4.5 liters per minute. No ambu-bag or replacement trach was observed at bedside.
On 4/20/21 at 2:49 PM, Resident #24's O2 setting on the oxygen concentrator flow meter was observed at 4.5 liters per minute. No ambu-bag or replacement trach was observed at bedside.
On 4/21/21 at 8:53 AM, Resident #24's O2 setting on the oxygen concentrator flow meter was observed at 4.5 liters per minute and verified by LPN (licensed practical nurse) #1. When asked the setting, LPN #1 stated, It is at 4.5 liters per minute and should be at 5 liters per minute. I'll set it to 5 liters per minute now.
A review of Resident #24's comprehensive care plan dated 2/6/21 and revised on 2/19/21, fails to evidence documentation of trach care. Comprehensive care plan, documents in part, FOCUS-The resident has altered respiratory status/difficulty breathing related to tracheostomy status. INTERVENTIONS-Administer medications as ordered elevate head of bed 30 degrees, monitor changes in orientation, anxiety and air hunger. Monitor for signs and symptoms of respiratory distress and report to physician. Monitor and report abnormal breathing patterns to physician. Position resident with proper body alignment for optimal breathing pattern.
A review of the physician orders dated 2/6/21, documented in part, Suction as needed to maintain patent airway and every shift. Trach care daily and as needed. Remove disposable and dispose of inner cannula. Replace with new inner cannula as needed to reduce the risk of infection.
A review of the admission evaluation dated 2/6/21, documented in part, Clinical evaluation respiratory: special treatments and procedures- oxygen therapy, tracheostomy and suctioning all were checked.
A review of the medical practitioner full assessment dated [DATE], documented in part, Trach placement 12/30/20. Diagnosis 1: acute respiratory failure, anoxic brain damage. Diagnosis 1 plan: O2 (oxygen) at 5 liters per minute via trach. Suction as needed and every shift to maintain patent airway. Trach care daily and as needed to remove and dispose of inner cannula. Replace with new inner cannula one time a day to reduce risk of infection.
A review of the April TAR (treatment administration record), documented in part, Trach care daily and as needed. Remove and dispose of inner cannula and replace with new inner cannula one time a day to reduce risk of infection. O2 at 5 liters per minute via trach every shift. Suction every shift and as needed to maintain patent airway. There were blank spaces (no documentation) on 4/12/21, 4/13/21 and 4/16/21 day shift for the treatments identified above.
Review of the clinical record failed to evidence any progress notes documenting tracheostomy care provided to Resident #24.
An interview was conducted on 4/21/21 at 8:53 AM with LPN #1, regarding the process for providing oxygen care and services. LPN #1 stated, We follow the physician's orders for oxygen therapy, suctioning and trach care. When asked if these services were documented, LPN #1 stated, They are documented on the TAR. When asked what emergency supplies should be kept at the bedside for a resident with a trach, LPN #1 stated, We keep the supplies in the supply room and go get them immediately if we need them. When asked what should be included in the comprehensive care plan regarding a tracheostomy, LPN #1 stated, Trach care should be on the care plan and it should follow the physician orders for frequency, changing the inner cannula and what to look for regarding secretions and skin redness.
An interview was conducted on 4/22/21 at 8:17 AM with RN (registered nurse) #3, the interim unit manager regarding the care provided to a resident with a tracheostomy. RN #3 stated, Trach care should include suctioning, frequency of dressing change, inner cannula change and cleaning.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concern on 4/22/21 at 5:15 PM.
The facility's Oxygen Administration policy revised 7/2017, documents in part, Oxygen concentrator, plug in power cord, turn unit on and set flow meter to correct flow rate. Suggested documentation- record oxygen administration on TAR.
The facility's Tracheostomy Care policy revised 7/2017, documents in part, A spare tracheostomy tube of the same size and type as well as an ambu-bag should be kept at the patient's bedside for emergency purposes. Verify medical practitioner's order and assemble equipment. Perform tracheostomy care, including disposable inner cannula change or cleaning of non-disposable inner cannula, at least once a day and as needed or indicated my medical practitioner's order. Suggested documentation: care provided in progress note including completion of procedure, evaluation of stoma, secretions, and tolerance of procedure.
The Perfecto Series User Manual, documents in part, 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 liters/minute line prescribed.
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 37.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 574.
2. The facility staff failed to provide oxygen at the prescribed rate to Resident #3.
Resident #3 was admitted to the facility with diagnoses that included but were not limited to heart failure (1) and cardiomyopathy (2).
Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/15/21 coded Resident #3 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O coded Resident #35 receiving oxygen while a resident at the facility.
On 4/20/21 at approximately 10:50 a.m., an interview was conducted with Resident #3 in their room. Resident #3 was observed lying in bed wearing a nasal cannula that was connected to an oxygen concentrator that was observed to the right of Resident #3 beside their bed. The oxygen concentrator flowmeter was observed set at 4 liters. Resident #3 stated that they wore the oxygen all the time at 4 liters. Resident #3 stated that they had problems with being able to feel the oxygen flow from the concentrator and the nurses would adjust it when needed. When Resident #3 was asked if they ever adjusted the oxygen flow themselves, Resident #3 laughed and stated, I do not have a right arm and I am bed ridden. I cannot reach the machine even if I wanted to. I have to call them to come and turn it up when I can't feel it.
On 4/20/21 at approximately 11:00 a.m., Resident #3 was observed leaving the facility on a stretcher wearing portable oxygen. Observation of the oxygen concentrator in Resident #3's room revealed it was off.
On 4/20/21 at approximately 1:30 p.m., Resident #3 was observed back in their room, with a nasal cannula in place connected to the oxygen concentrator. Observation of the oxygen concentrator flowmeter revealed the oxygen flow rate was set at 4 liters.
Additional observations on 4/21/21 at 9:10 a.m. and 3:30 p.m., of Resident #3's oxygen flowrate revealed the same findings as above.
The physician orders for Resident #3 documented in part, .O2 (oxygen) @ (at) 2 (two) liters per minute via nasal cannula every shift for supplemental oxygen. Order Date: 02/02/2021 .
The comprehensive care plan for Resident #3 dated 5/20/2015 documented in part, Resistive/non-compliant with treatment/care related to : refusing showers, getting out of bed says he has been in bed for years and not changing now, refusing meds (medications), removes oxygen, refuses vital signs and therapy, refuses non-pharmacological interventions prior to PRN (as needed) medications, consistently in positions that can contribute to skin breakdown, stating he is going to remove life vest (3). Date Initiated: 05/20/2015. Revision on: 09/18/2020. It further documented, Cardiac disease related to Hypertension (high blood pressure), cardiomyopathy, CHF (congestive heart failure). Date Initiated: 03/17/2016. Under Interventions it documented in part, .O2 as ordered, encourage resident to keep oxygen tubing on and notify nurse if resident will not keep oxygen on. Date Initiated: 09/19/2018. Revision on 03/24/2020 .Administer medication per physician orders. Date Initiated: 03/17/2016 .
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that the oxygen flow rate was checked at least every shift but should be checked each time the nurse enters the room. LPN #8 stated that the ball on the flowmeter of the concentrator should be centered on the line of the oxygen setting. On 4/22/21 at approximately 8:15 a.m., LPN #8 observed Resident #3's oxygen which was set at 2 liters. Resident #3 stated that a nurse who he did not know came in a few minutes before and changed the oxygen to 2 liters. Resident #3 stated that they could not feel any oxygen coming out of the cannula now and felt like they were not getting any oxygen. LPN #8 advised Resident #3 that they had set the oxygen to the rate the physician ordered this morning and they were contacting their physician to have the order changed to increase the oxygen to 4 liters.
The facility policy Oxygen Administration dated Updated: 07/2017, documented in part, .Application of Nasal cannula: .5. Set flow rate .
The manufacturer's instructions for use provided by the facility for the oxygen concentrator used by Resident #3 documented in part, .Warning. Do not change the L/min (liters per minute) setting on the flowmeter unless a change has been prescribed by your physician or therapist. Note: 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 line prescribed .
On 4/22/21 at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
On 4/22/21 at approximately 5:00 p.m., ASM #3, the quality consultant stated that staff reported to them that Resident #3 had adjusted the oxygen themselves this morning after they changed it to 2 liters and they had been educated to not adjust the oxygen themselves and updated their care plan. When informed that the resident was asked if he adjusted the oxygen and the resident stated he does not have a right arm and is bed ridden and cannot reach the machine even if he wanted to. ASM stated that's what the staff reported to me.
No further information was provided prior to exit.
Reference:
(1). Heart failure
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.
(2). Cardiomyopathy
Disease in which the heart muscle becomes weakened, stretched, or has another structural problem. It often occurs when the heart cannot pump or function well. Most people with cardiomyopathy have heart failure. This information was obtained from the website: https://medlineplus.gov/ency/article/001105.htm.
(3). Life vest
The LifeVest® wearable cardioverter defibrillator (WCD) is designed to protect patients at risk of sudden cardiac death (SCD), when a patient's condition is changing and permanent SCD risk has not been established. This information was obtained from the website: https://lifevest.[NAME].com/
3. During separate observations, Resident #44's tracheostomy mask, tubing and humidifier bottle were observed undated and there was no ambu bag was observed in Resident #44's room per the facility policy for a resident with a trachesotomy.
Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (1) and tracheostomy (2).
Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/12/21 coded Resident #44 as being non-verbal and severely impaired of making daily decisions. Section G coded Resident #44 as totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependent on one staff member for eating and personal hygiene. Section O coded Resident #44 receiving oxygen, suctioning and tracheostomy care while a resident at the facility.
The physician orders for Resident #44 documented in part, .Cool air mist via trach collar (oxygen mask) continuous with O2 (oxygen) titrated in at 5 liters every shift for respiratory failure. (3) Order Date: 12/03/2020 . PRN (as needed) as needed for trach [tracheostomy] care. Order Date: 05/28/2020 .
The comprehensive care plan for Resident #44 dated 12/15/2020 documented in part, Has/At risk for respiratory impairment related to tracheostomy. Date Initiated: 12/15/2020. Revision on: 03/16/2021. Under Interventions it documented in part, .Administer oxygen as per physician order: 5 L (liter) via cool mist humidifier. Date Initiated: 12/15/2020 .Maintain replacement trach tube and Ambu bag (4) at bedside. Date Initiated: 12/15/2020 .
On 4/20/21 at approximately 10:45 a.m., an observation was conducted of Resident #44 in their room. Resident #44 was observed in bed and was observed with a tracheostomy. Resident #44 was observed wearing a tracheostomy mask (oxygen delivery device) delivering oxygen at 5 lpm (liters per minute). The humidifier bottle attached to the oxygen tubing was observed empty. The tracheostomy mask, tubing and humidifier bottle were observed undated. No ambu bag was observed in Resident #44's room.
Additional observations on 4/20/21 at 1:34 p.m. revealed the findings as above. On 4/21/21 at approximately 9:30 a.m., the humidifier bottle attached to the oxygen tubing delivering oxygen to Resident #44 was observed half full. The tracheostomy mask, tubing and bottle remained undated. No ambu bag was observed in Resident #44's room.
On 4/21/21 at approximately 3:15 p.m., an interview was conducted with RN (registered nurse) #6, the unit manager. RN #6 stated that ambu bags were kept on the emergency cart at the nurse's station and were not kept in Resident #44's room. RN #6 stated that if Resident #44's tracheostomy became dislodged or removed accidentally they would go to the supply closet to obtain another tracheostomy and to the emergency cart to get the ambu bag. RN #6 stated that the only emergency supplies kept in Resident #44's room were suction equipment, suction catheters and the tracheostomy cleaning kit and proceeded to point out where they were kept in Resident #44's room. RN #6 stated that they did not keep ambu bags in any resident rooms in the facility.
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that oxygen supplies were changed weekly and were dated when put into use. LPN #8 stated that they were supposed to keep suction equipment, extra tracheostomy tubes and ambu bags in the rooms of residents with a tracheostomy. LPN #8 observed Resident #44's room and stated that there were extra tracheostomy inner cannulas in the wardrobe drawer along with suction catheters and tracheostomy cleaning kits but there was no ambu bag. LPN #8 stated that there was no date on the oxygen mask, tubing or bottle. LPN #8 stated that the ambu bag was located on the emergency cart at the nurse's station.
The facility policy Oxygen Administration dated updated: 07/2017 documented in part, .Change all tubing and masks as per state protocol and label with date and initials .
The facility policy Tracheostomy Care dated updated 07/2017 documented in part, .Note: A spare tracheostomy tube of the same size and type should be kept at the patient's bedside for emergency purposes. An Ambu-bag should also be kept at the patient's bedside with attachment to fit trach .
On 4/22/21 at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
Reference:
(1). Intracerebral hemorrhage
Bleeding in the brain caused by the breaking (rupture) of a blood vessel in the head. This information was obtained from the website: http://pacificschoolserver.org/med/ency/article/000796.htm.
(2). Tracheostomy
A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.
(3). Respiratory failure
When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.
(4). Ambu bag
A self-refilling bag-valve-mask unit with a 1-1.5 litre capacity, used for artificial respiration which, while suboptimal for the non-intubated patient, is effective for ventilating and oxygenating intubated patients, allowing both spontaneous and artificial respiration. This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/Ambu+bag
4. The facility staff failed to provide respiratory services in a sanitary manner for Resident #35. During [NAME] observations, Resident #35's tracheostomy collar mask was observed hanging on the humidifier bottle of the machine uncovered. There was no date observed on the mask and mask tubing and there was no ambu bag observed in Resident #35's room per the facility policy for a resident with a tracheostomy.
Resident #35 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of base of tongue (1) and tracheostomy (2).
Resident #35's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/3/21 coded Resident #35 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Section O coded Resident #35 receiving suctioning and tracheostomy care while a resident at the facility.
The comprehensive care plan for Resident #35 dated 5/29/2020 documented in part, Has/At risk for respiratory impairment related to tracheostomy secondary to tongue malignancy. Date Initiated: 05/29/2020. Revision on: 05/29/2020. Under Interventions it documented in part, .treatments per md (medical doctor) orderers [sic] Date Initiated: 05/29/2020 . Administer medications/treatments per physicians orders. Date Initiated: 05/29/2020 .Maintain replacement trach [tracheostomy] tube and Ambu bag (3) at bedside. Date Initiated: 12/15/2020 .
The physician orders for Resident #35 documented in part, .Cool air mist via trach collar (oxygen mask) PRN (as needed) as needed for trach care. Order Date: 05/28/2020 .
The eMAR (electronic medication administration record) and eTAR (electronic treatment administration record) dated 4/1/2021-4/30/2021 for Resident #35 failed to evidence documentation of the cool air mist via trach collar as needed or cleaning or replacement of the trach collar.
On 4/20/21 at approximately 10:30 a.m., an observation was conducted of Resident #35 in their room. Resident #35 was observed sitting on the side of their bed wrapping a compression bandage around their knee. Resident #35 was observed with a tracheostomy in place. Resident #35 was observed to have a humidifier machine and suction machine on their nightstand beside the bed. A tracheostomy collar mask was observed hanging on the humidifier bottle of the machine uncovered. The mask was observed to contain visible debris. There was no date observed on the mask and mask tubing. When asked if they used the humidifier and mask, Resident #35 nodded and stated Yes. When asked if the staff kept the water in the bottle and took care of the mask, Resident #35 nodded again and stated Yes. Resident #35 stated that they wore the mask at night. There was no ambu bag observed in Resident #35's room.
Additional observations on 4/20/21 at 1:45 p.m. revealed the same findings as above. On 4/21/21 at approximately 10:30 a.m. and 3:15 p.m., observations of Resident #35's room revealed the mask hanging on the humidifier bottle attached to the machine uncovered but no visible debris on the mask. The tracheostomy mask, tubing and bottle remained undated and observations failed to reveal an ambu bag in Resident #35's room.
On 4/21/21 at approximately 3:15 p.m., an interview was conducted with RN (registered nurse) #6, the unit manager. RN #6 stated that ambu bags were kept on the emergency cart at the nurse's station and were not kept in any resident rooms.
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that oxygen supplies were changed weekly and were dated when put into use. LPN #8 stated that masks were stored in plastic bags that were dated when not in use. LPN #8 stated that they were stored in the bags to keep them clean. LPN #8 observed Resident #35's room and stated that Resident #35 managed applying their humidifier mask themselves and removed it themselves so that was why it was left hanging on the bottle. LPN #8 stated that it should have had a date on it and should be changed weekly. LPN #8 stated that the staff should still monitor Resident #35 when they are applying and removing their mask to ensure that it is kept clean and changed weekly. LPN #8 stated there was no bag in Resident #35's room for their mask because they managed it themselves. LPN #8 stated that it should be on their care plan if the resident self managed their treatment and did not comply with storage of the mask. LPN #8 asked Resident #35 if they wore their humidifier mask the previous night and Resident #35 stated, Yes. LPN #8 stated that they were going to obtain a new mask and tubing and date them so they would know when they needed to be changed. LPN #8 stated that an ambu bag needed to be placed in Resident #35's room.
The facility policy Oxygen Administration dated updated: 07/2017 documented in part, .When oxygen not in use, store oxygen tubing and nasal cannula or mask in separate, labeled plastic bag .Change all tubing and masks as per state protocol and label with date and initials .
On 4/22/21 at approximately 9:45 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
Reference:
(1). Malignant neoplasm
The term malignancy refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. Malignant cells tend to have fast, uncontrolled growth and DO NOT die normally due to changes in their genetic makeup. Malignant cells that are resistant to treatment may return after all detectable traces of them have been removed or destroyed. This information was obtained from the website: https://medlineplus.gov/ency/article/002253.htm.
(2). Tracheostomy
A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.
(3). Ambu bag
A self-refilling bag-valve-mask unit with a 1-1.5 liter capacity, used for artificial respiration which, while suboptimal for the non-intubated patient, is effective for ventilating and oxygenating intubated patients, allowing both spontaneous and artificial respiration. This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/Ambu+bag
7. For Resident #25, the facility failed to evidence tracheostomy care from 2/9/21 through 3/3/21.
Resident #25 was admitted to the facility on [DATE] with diagnoses including epilepsy, COPD (chronic obstructive pulmonary disease) (1), and diabetes (2). The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/16/21, coded Resident #25 as \moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). He was coded as being totally dependent on the assistance of staff members for all activities of daily living. He was coded as having a tracheostomy (3) in place.
Resident #25 declined to be interviewed during the survey.
On the following dates and times: 4/20/21 at 11:40 a.m., 4/20/21 at 12:47 p.m., 4/20/21 at 1:48 p.m., and 4/21/20 at 9:11 a.m., Resident #25 was observed lying on his back in bed. During each observation the resident was observed with a tracheostomy in place.
A review of Resident #25's admission nursing assessment dated [DATE] revealed documentation confirming Resident #25 had a tracheostomy in place on admission.
A review of Resident #25's physicians' orders revealed the following order, dated 3/4/21: Trach (tracheostomy) care Q (every) shift, every shift. There was no physician's order for trach care prior to 3/4/21.
A review of Resident #25's TARs (treatment administration records) revealed no evidence of trach care being administered by facility staff prior to 3/4/21.
Further review of Resident #25's clinical record revealed no evidence of any respiratory infections since his admission to the facility on 2/9/21.
A review of Resident #25's comprehensive care plan dated 2/22/21 revealed, in part: Has/At risk for respiratory impairment related to COPD, tracheostomy .Trach care per protocol.
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked if she takes care of Resident #25 regularly, she stated she does. When asked if it is important to provide trach care to the resident as ordered by the physician, LPN #2 stated it is. She stated the trach care helps prevent the resident from getting a respiratory infection. LPN #2 stated she provides trach care for the resident during every shift she works.
On 4/22/21 at 2:07 p.m., LPN #5 was interviewed. When asked if a resident who is admitted with a trach should have orders for trach care, LPN #5 stated yes. She stated the nurse who completes a resident's admission assessment is responsible for making certain there are orders for trach care. LPN #5 stated if a resident does not receive trach care, they are at a high risk for developing a respiratory infection.
On 4/22/21 at 5:17 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and ASM #3, the quality consultant, were informed of these concerns.
On 4/23/21 at 10:08 a.m., ASM #3 stated evidence that Resident #25 received trach care between 2/9/21 and 3/3/21 does not exit.
A review of the facility policy, Tracheostomy Care, revealed, in part: Purpose: To describe a recommended method for cleaning a tracheostomy site and tube; keeping site and tube free from mucus build up; maintaining tube patency; reducing risk of infection; and maintaining skin integrity at stoma site .Note: Perform tracheostomy care, including disposable inner cannula change or cleaning of non-disposable inner cannula, at least one a day and prn (as needed) or as indicated by medical practitioner's order.
No further information was provided prior to exit.
REFERENCES
(1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.
(3) A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information is taken from the website https://medlineplus.gov/ency/article/002955.htm.
Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for seven of 25 residents in the survey sample, Residents #61, #3, #44, #35, #11, #24 and #25.
The facility staff failed to administer a CPAP (1) machine per physician's order to Resident #61, failed to provide oxygen at the prescribed rate to Residents #61, #3, #11, and #24.
The staff failed to ensure tracheostomy care was provided as ordered by the physician to Resident #24 on 4/12/21, 4/13/21 and 4/16/21 day shift, and to Resident #25 from 2/9/21 through 3/3/21 and, failed to ensure Resident #44's tracheostomy mask, tubing and humidifier bottle were dated to determine when the tubing needed to be changed, failed provide respiratory services in a sanitary manner for Resident #35, the residents tracheostomy collar mask was observed undated, hangi[TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #67, the facility staff failed to obtain a physician's order for dialysis (1), failed to follow a physician's or...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #67, the facility staff failed to obtain a physician's order for dialysis (1), failed to follow a physician's order for fluid restriction, failed to evidence documentation of assessment of her dialysis access site, and failed to maintain communication with the dialysis center.
Resident #67 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including ESRD (end stage renal disease) (2), diabetes (3), lymphedema (4), and bipolar disorder (5). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 4/12/21, Resident #67 was coded as having no cognitive impairment for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). She was coded as receiving dialysis services.
Resident #67 refused to be interviewed regarding dialysis.
On the following dates and times: 4/20/21 at 11:38 a.m., 4/20/21 at 12:40 p.m., 4/20/21 at 1:45 p.m., 4/21/21 at 9:11 a.m., and 4/21/21 at 2:46 p.m., observations revealed Resident #67 was lying on her back in the bed.
A review of Resident #67's clinical record revealed a readmission nursing assessment dated [DATE]. On this assessment, Resident #67 was documented as requiring hemodialysis, and documented as having a right upper chest catheter as the hemodialysis access site.
Further review of Resident #67's clinical record revealed progress notes documenting Resident #67's leaving the facility and receiving hemodialysis on the following dates: 2/19/21, 3/3/21, 3/15/21, 3/17/21, 4/2/21, 4/5/21, 4/7/21, and 4/19/21.
Further review of Resident #67's clinical record failed to reveal a physician's order for hemodialysis, for assessment of her access site for bruit and thrill (6), or for fluid restriction after her readmission on [DATE].
A review of Resident #67's MARs (medication administration record) and TARs (treatment administration records) since 2/17/21 revealed no evidence of dialysis services, including site assessment or fluid restriction.
A review of Resident #67 dialysis communication book revealed no evidence of any dialysis communication between the facility and dialysis center on 2/19/21, 3/3/21, 3/15/21, and 3/17/21. The dialysis communication book contained no communication from the dialysis center to the facility on 4/2/21 and 4/5/21.
A review of Resident #67's comprehensive care plan, dated 11/8/2020 and updated 4/1/21, revealed, in part: Renal insufficiencies related to chronic renal failure .Check access site for lack of thrill/bruit, evidence of infection, swelling, or excessive bleeding per facility guidelines .Confer with physician and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis and as needed .Coordinate dialysis care with dialysis treatment center .Dialysis 3X (three times) per week, T, TH, SA (Tuesday, Thursday, Saturday), fluid restriction 1500 mls (milliliters)/24 hours (in 24 hours).
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked if she takes care of Resident #67, she stated she does. When asked if Resident #67 receives dialysis, she stated the resident does sometimes. LPN #2 stated the resident is scheduled to go three times a week, but the resident is noncompliant, and frequently refuses to go to dialysis. When asked if Resident #67 should have an order for dialysis, LPN #2 stated the resident should have an order. She stated the resident should also have an order for assessment of her right upper chest port. When asked if Resident #67 is on a fluid restriction, LPN #2 stated, I thought so, but now I'm not so sure. She stated Resident #67 has problems with too much fluid and lymphedema, and she knows the resident was on a fluid restriction prior to being discharged from the facility and readmitted on [DATE]. LPN #2 stated the dialysis communication should always be filled out at the facility, then sent with the resident to dialysis. She stated the dialysis center should fill out their portion of the form, and return the communication book with the resident. LPN #2 stated this is important because, We want to know what they did to her. She stated if the dialysis book is returned to the facility with no information from the dialysis center, she would call the dialysis center and get a verbal report.
On 4/21/21 at 6:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and ASM #3, the quality consultant, were informed of these concerns. ASM #3 stated the communication form has two parts, and that the top of the form is filled out by facility staff. It includes the resident's vital signs, medications administered, and any other information the dialysis center might need to take care of a resident. The form is sent to the dialysis center with the resident. The bottom of the form should be filled out by dialysis center staff, including vital signs, weights, laboratory studies, or any other pertinent information regarding the resident's dialysis that day. The form is then returned to the facility. When asked how often this form should be utilized by both facility and dialysis center staff, ASM #3 stated it should be used every time the resident receives dialysis. When asked what the facility staff should do if the dialysis center has not filled out its portion of the form, ASM #3 stated the facility nurse should contact the dialysis center and get the information from the dialysis center staff. She stated this is important so the facility staff can know if any changes occurred in the resident's condition.
On 4/22//21 at 1:41 p.m., LPN #5 was interviewed regarding the process staff follows for re-initiating orders for dialysis services when a resident is readmitted . LPN #5 stated, We go by what the doctor orders. When asked if she ever looks back to check a resident's orders before they were discharged to the hospital, she stated she does, sometimes. She stated if a resident should be on a fluid restriction, the fluid intake should be carefully tracked, and should be a coordinated effort between dietary staff and nursing. She stated the admitting nurse is responsible for making sure all orders are put into the electronic medical record (EMR).
On 4/23/21 at 10:08 a.m., ASM #3 confirmed the orders for Resident #67's dialysis services, including receiving dialysis, fluid restriction, and assessment of access site were not a part of her current clinical record. ASM #3 stated, It just got missed.
No further information was provided prior to exit.
REFERENCES
(1) When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called dialysis. There are two main types of dialysis. Both types filter your blood to rid your body of harmful wastes, extra salt, and water. Hemodialysis uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. This information was taken from the website https://medlineplus.gov/dialysis.html.
(2) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease (ESRD). This information is taken from the website https://medlineplus.gov/ency/article/000500.htm.
(3) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html.
(4) Lymphedema (LE) is the accumulation of protein-rich fluid in tissues. The impaired function of lymph vessels interrupts the drainage of lymphatic system that is a part of the circulatory system just like the arterial and venous structures. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508242/#:~:text=Lymphedema%20(LE)%20is%20the%20accumulation,the%20arterial%20and%20venous%20structures.
(5) Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. This information is taken from the website https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.
(6) Your access is your lifeline. You will need to protect your access. Wash the area around your access with soap and warm water every day. Check the area for signs of infection, such as warmth or redness. When blood is flowing through your access and your access is working well, you can feel a vibration over the area. Let your dialysis center know if you can't feel the vibration. This information is taken from the website https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis.
Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide dialysis services for two of 25 residents in the survey sample, (Residents #19 and #67).
1. The facility staff failed to ensure communication regarding Resident #19's care with the dialysis center, failed to assess the resident's dialysis access site per physician's order, failed to follow up on a fluid restriction recommendation from Resident #19's dialysis RD (registered dietician).
2. For Resident #67, the facility staff failed to obtain a physician's order for dialysis (1), failed to follow a physician's order for fluid restriction, failed to evidence documentation of assessment of her dialysis access site, and failed to maintain communication with the dialysis center.
The findings include:
1.a. The facility staff failed to ensure communication regarding Resident #19's care with the dialysis center.
Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to end stage renal disease, diabetes and muscle weakness. Resident #19's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/7/21 coded the resident as being cognitively intact.
Review of Resident #19's clinical record revealed a physician's order dated 4/12/21 for dialysis every Monday, Wednesday and Friday.
Resident #19's comprehensive care plan dated 2/11/21 documented, Renal insufficiencies related to: chronic renal failure with anemia. Coordinate dialysis care with dialysis treatment center .
Further review of Resident #19's clinical record failed to reveal any documented communication between the facility staff and dialysis center staff. A dialysis communication book labeled with Resident #19's name contained the resident's face sheet, physician order sheet and four blank dialysis communication forms.
On 4/20/21 at 1:44 p.m., an interview was conducted with Resident #19. The resident stated she had not seen a dialysis communication book since she was admitted to the facility.
On 4/21/21 at 2:57 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses are supposed to document residents' pre-dialysis vital signs in residents' dialysis communication books and send the books to the dialysis center. LPN #2 stated communication with the dialysis center is important because the facility nurses want to know what was done at the dialysis center. LPN #2 stated she would call the dialysis center if residents returned from dialysis without documented information.
On 4/21/21 at 6:08 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility dialysis guidelines documented Both the center and the dialysis facility are responsible for shared communication regarding patients receiving dialysis services, either onsite or offsite. The Hemodialysis Communication Form is to be used .
No further information was presented prior to exit.
1.b. The facility staff failed to assess Resident #19's dialysis access site per physician's order.
Review of Resident #19's clinical record revealed a physician's order dated 2/1/21 to check the AV (arteriovenous) fistula site (1) thrill (vibration) and bruit (buzzing) every shift.
Review of TARs (treatment administration records) for February 2021 through April 2021 failed to reveal evidence that the thrill and bruit was checked as evidenced by blank spaces of the TARs, on the following dates:
2/7/21 at 11:15 (a.m. or p.m. was not specified)
2/9/21 at 3:15 p.m.
2/12/21 at 7:15 a.m.
2/13/21 at 3:15 p.m.
3/2/21 at 7:15 a.m.
3/7/21 at 3:15 p.m.
3/9/21 at 7:15 a.m. and 3:15 p.m.
3/11/21 at 7:15 a.m.
3/13/21 at 3:15 p.m.
3/14/21 at 3:15 p.m.
3/15/21 at 7:15 a.m. and 3:15 p.m.
3/16/21 at 7:15 a.m. and 3:15 p.m.
3/17/21 at 7:15 a.m.
3/18/21 at 3:15 p.m. and 11:15 (a.m. or p.m. was not specified)
3/23/21 at 3:15 p.m.
3/25/21 at 3:15 p.m.
3/26/21 at 7:15 a.m. and 3:15 p.m.
3/31/21 at 3:15 p.m.
4/1/21 at 7:15 a.m.
4/11/21 at 3:15 p.m.
4/13/21 at 7:15 a.m.
Review of nurse's notes for the above dates only revealed documentation of assessment of Resident #19's thrill and bruit on 2/13/21 at 2:28 a.m., 3/2/21 at 9:21 p.m., 3/17/21 at 11:29 p.m. and 3/25/21 at 11:03 p.m.
Resident #19's comprehensive care plan dated 2/11/21 documented, Renal insufficiencies related to: chronic renal failure with anemia. Check access site for lack of thrill/bruit, evidence of infection, swelling, or excessive bleeding per facility guidelines. Report abnormalities to physician .
On 4/20/21 at 1:44 p.m., an interview was conducted with Resident #19. Resident #19 stated the nurses only check her AV fistula for thrill and bruit every once in a while.
On 4/21/21 at 5:02 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated you can't say a treatment was done if it is not signed off on the TAR. LPN #3 stated she was told that if it wasn't documented, it wasn't done.
On 4/21/21 at 6:08 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility guidelines regarding assessment of AV shunts, fistulas and grafts documented, The evaluation of arteriovenous shunts, fistulas, and grafts by a licensed nurse is intended to facilitate early detection of potential complications which includes signs and symptoms of infection, leakage, and thrombosis. Any abnormal signs and symptoms should be reported to the physician .Document completion of observation or assessment on TAR .
No further information was presented prior to exit.
Reference:
(1) The best type of long-term access is an AV fistula. A surgeon connects an artery to a vein, usually in your arm, to create an AV fistula. An artery is a blood vessel that carries blood away from your heart. A vein is a blood vessel that carries blood back toward your heart. When the surgeon connects an artery to a vein, the vein grows wider and thicker, making it easier to place the needles for dialysis. The AV fistula also has a large diameter that allows your blood to flow out and back into your body quickly. The goal is to allow high blood flow so that the largest amount of blood can pass through the dialyzer. This information is taken from the website https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis.
1.c. The facility staff failed to follow up on a fluid restriction recommendation from Resident #19's dialysis RD (registered dietician).
Review of Resident #19's clinical record revealed a nutrition note dated 2/10/21, signed by the former facility RD that documented, The resident spoke with the Kitchen manager requesting a regular diet. She reports to staff and her renal dietitian that she consumes a regular diet at home. Per Renal RD, her labs [laboratory tests] are typically WNL (within normal limits) and they have no concerns with a diet change at this time .RD recommended fluid restriction but no specific value was obtained. Will discuss these changes with the resident and kitchen staff.
Further review of Resident #19's clinical record failed to reveal the facility RD discussed a fluid restriction with Resident #19 or the dietary manager and failed to reveal the facility RD followed up with the renal RD regarding a fluid restriction.
Resident #19's comprehensive care plan dated 2/11/21 documented, Renal insufficiencies related to: chronic renal failure with anemia. Coordinate dialysis care with dialysis treatment center . The care plan failed to document specific information regarding fluid restrictions.
The former facility RD was no longer employed at the facility.
On 4/21/21 at 2:41 p.m., an interview was conducted with OSM (other staff member) #5, the newly employed facility RD. OSM #5 was shown the above nutrition note and was asked what should have been done in regards to a fluid restriction for Resident #19. OSM #5 stated he would call the renal RD back to discuss specific details. OSM #5 stated he had not yet called the renal RD but he was planning on calling and making sure that he and the renal RD were on the right page. OSM #5 stated he does communicate with renal RDs and does talk about fluid restrictions because the renal RDs are the ones that follow the fluids that are taken out of residents at dialysis.
On 4/22/21 at 9:43 a.m., an interview was conducted with Resident #19. Resident #19 stated she manages her own fluid restriction by drinking one cup of fluids with each meal then one additional cup each day. Resident #19 stated no facility staff had spoken with her regarding a fluid restriction.
On 4/22/21 at 12:40 p.m., an interview was conducted with OSM #6 (the dietary manager). OSM #6 stated the former RD did not speak to him regarding a fluid restriction for Resident #19.
On 4/21/21 at 6:08 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the quality consultant) were made aware of the above concern.
The facility dialysis guidelines documented Both the center and the dialysis facility are responsible for shared communication regarding patients receiving dialysis services, either onsite or offsite .
The facility fluid restrictions guideline documented, Fluid restrictions are sometimes used for patients with renal failure, congestive heart failure and hyponatremia (low sodium), or other condition requiring that intake of fluids be minimized. Specific total fluid restrictions are ordered by the physician and communicated to the dietary department.
No further information was presented prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. The facility staff failed to document the provision of physician ordered treatments to Resident #24 on multiple dates in Apri...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. The facility staff failed to document the provision of physician ordered treatments to Resident #24 on multiple dates in April 2021.
Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3).
Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS Section G- Functional Status: coded the resident as dependent with bed mobility, transfers, dressing, eating, personal hygiene and bathing; walking and locomotion did not occur. A review of MDS Section O- Special treatments, procedures and programs: coded the resident as tracheostomy 'yes' and oxygen therapy 'yes'.
A review of Resident #24's comprehensive care plan dated 2/6/21 and revised on 2/19/21, fails to evidence documentation of trach care. Comprehensive care plan, documents in part, FOCUS-The resident has altered respiratory status/difficulty breathing related to tracheostomy status. INTERVENTIONS-Administer medications as ordered elevate head of bed 30 degrees, monitor changes in orientation, anxiety and air hunger. Monitor for signs and symptoms of respiratory distress and report to physician. Monitor and report abnormal breathing patterns to physician. Position resident with proper body alignment for optimal breathing pattern.
A review of the TAR (treatment administration record), for April 2021 documented in part the following:
1. Body Audit daily three of 21 opportunities not documented as completed as follows: 4/12/21, 4/13/21 and 4/16/21 day shift.
2. Trach care daily and as needed, remove and dispose of inner cannula, replace with new inner cannula, one time a day and as needed to reduce risk of infection three of 21 opportunities were not documented as follows: 4/12/21, 4/13/21 and 4/16/21 day shift.
3. Foley cath [catheter] care every shift, five of 63 opportunities for care were not documented as provided as follows: 4/12/21, 4/13/21 and 4/16/21 day shift; 4/11/21 and 4/21/21 evening shift.
4. Oxygen at 5 liters per minute via trach every shift five of 63 opportunities were not documented as follows: 4/12/21, 4/13/21 and 4/16/21 day shift; 4/11/21 and 4/21/21 evening shift.
5. Pressure relieving boots in place as tolerated every shift for prevention five of 63 opportunities were not documented as follows: 4/12/21, 4/13/21 and 4/16/21 day shift; 4/11/21 and 4/21/21 evening shift.
6. Skin prep right heel every shift for prevention five of 63 opportunities were not documented as follows: 4/12/21, 4/13/21 and 4/16/21 day shift; 4/11/21 and 4/21/21 evening shift.
7. Suction every shift and as needed to maintain patent airway five of 63 opportunities were not documented as follows: 4/12/21, 4/13/21 and 4/16/21 day shift; 4/11/21 and 4/21/21 evening shift.
On 4/20/21 at 10:40 AM, during entrance conference, when asked about the standards of practice followed by the facility, ASM (administrative staff member) #2, the director of nursing and ASM #3, the quality consultant stated, We use [NAME] and [NAME] & Potter.
On 4/23/21 at 8:41 AM, an interview was conducted with LPN (licensed practical nurse) #1. When asked if she cared for Resident #24, LPN #1 stated, I cared for her on 4/16/21 day shift. LPN #1 stated, There are times there are widgets and it won't save. We can save and go back the next day and see that it does not save. I did provide all of the care to that resident on that day last week.
An interview was conducted on 4/23/21 at 9:13 AM, with RN (registered nurse) #4. When asked if she cared for Resident #24 and on what dates, RN #4 stated, I cared for her on 4/12/21 day shift. RN #4 stated, I would have done her trach and Foley care. I did do the care but I got busy and forgot to sign them off. If there are blanks, it does not mean they were not done, they were just not signed off.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concern on 4/22/21 at 5:15 PM.
The facility's Oxygen Administration policy revised 7/2017, documents in part, and Suggested documentation- record oxygen administration on TAR.
According to Lippincott Nursing Procedures, Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Document information as soon as possible to ensure the accuracy of the information and to reflect ongoing care. Delayed documentation increases the potential for omissions, errors and inaccuracy due to memory lapse. (4)
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 37.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 574.
(4) Lippincott Nursing Procedure, 8th edition, Wolters Kluwer, pages 236-238.
8. Resident #47 was given all of her physician prescribed evening medications twice on 7/2/2020, by two nurses, transferred to the hospital and admitted . Resident #47's clinical record failed to evidence any progress notes and or documentation regarding the medications administered or the incident.
Resident #47 was admitted to the facility on [DATE] and transferred to the hospital on 7/2/20 after a significant medication error.
Resident #47's diagnoses included but were not limited to: bipolar disorder (mental disorder characterized by periods of mania and depression) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2), diabetes mellitus (inability of insulin to function normally in the body) (3) and atherosclerosis cardiac disease (disorder of the cardiac arteries caused by a buildup of plaque which results in the vessels becoming non-elastic) (4).
Resident #47's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/15/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring limited assistance with mobility, transfers, dressing; supervision with personal hygiene and bathing and independence in eating and locomotion.
The comprehensive care plan dated 6/4/18 with a target date of 7/2/21, documented in part, FOCUS-Cardiac disease related to hyperlipidemia, hypertension and coronary artery disease. INTERVENTIONS-Administer medication per physician orders. FOCUS-Endocrine System related to diabetes. INTERVENTIONS-Administer medication per physician orders. FOCUS-Neurological deficiencies related to history of seizure activity. INTERVENTIONS-Administer medication per physician orders. FOCUS-Diuretic therapy at risk for adverse effects. INTERVENTIONS-Administer medication per physician orders. FOCUS-The resident has the potential for hydration/nutrition imbalance related to multiple medical diagnosis, diabetes mellitus, therapeutic diet, obesity, non-compliant with diet at times. INTERVENTIONS-Administer medication as orders.
The physician orders for Resident #47 in July 2020, documented in part the following:
Medications scheduled administration time 5:00 PM:
- Losartan (anti-hypertensive) (5) 100 milligram table by mouth in the afternoon for hypertension
- Multivitamin (dietary supplement) 1 tablet by mouth in the afternoon for supplement,
- Divalproax [Depakote] (anti-epileptic) (6) 625 milligram delayed response tablet twice a day for seizure prevention,
- Metformin (anti-diabetic) (7) extended release tablet 500 milligram by mouth twice a day for diabetes mellitus,
- Olopatadine (treats allergic conjunctivitis) (8) solution 0.1% instill 1 drop in both eyes twice a day for allergies,
- Humalog (insulin) (9) 100 units/milliliter inject per sliding scale: if BS (blood sugar) 150-200 =4 units, BS 201-250=6 units, BS 251-300=8 units, BS 301-350=10 units, BS 351-400=12 units. If < 60 or > 350 or greater call physician, subcutaneously before meals for diabetes.
Medications scheduled administration time 9:00 PM:
- Atorvastin (anti-hyperlipidemic) (10) 10 milligram tablet by mouth at bedtime to lower cholesterol
- Cetirizine (antihistamine) (11) 5 milligram tablet at bedtime for allergies
- Gabapentin (anti-epileptic) (12) 600 milligram tablet at bedtime for nerve pain
- Melatonin (treatment for insomnia) (13) milligram tablet by mouth at bedtime for sleep
- Ziprasidone (antipsychotic) (14) 40 milligram capsule at bedtime for bipolar
Bisoprolol (antihypertensive) (15) 10 milligram twice a day for hypertension
The FRI (facility reported incident) provided to Virginia Department of Health-Office of Licensure and Certification, Long Term Care (VDH-OLC-LTC) dated 7/3/20 with incident date of 7/2/20, documented in part, Resident was given evening medication [medications listed above] twice by two nurses. Resident's nurse practitioner (NP) requested the resident be sent to the hospital to be monitored due to the medication and her low bp / pulse. Resident was admitted at the hospital for observation.
Review of the FRI investigation and follow up, documented in part, the following:
Facility investigation: Completed on: the date 7/8/2020 was handwritten on the form. An included attachment documented in part the following:
7-8-2020
FRI day 5
On 7/2/2020 it was reported that a resident was given medication twice by two different nurses. During the investigation it was found that the resident was written on two different assignment sheets, [name of LPN #4] gave the medication first, without documenting the medication in the system. [Name of RN #2] gave the medication second. The MD [medical doctor] was notified and gave an order to send the resident to the ER [emergency room]. Resident [#47] was sent to the hospital and remained there two nights under observation status. Resident [#47] returned to the facility on 7/4/2020 with no adverse reactions from the medication error and has remained stable. The DON [director of nursing] removed both nurses from the schedule while the investigation was ongoing, reconfigured the assignment sheets as well as educated the nursing staff on proper medication documentation. The investigation is complete.
Review of Resident #47's clinical record to include the progress notes, electronic medication administration record (eMar) for 7/2/20, failed to evidence any progress note documenting the medication error event, vital signs (blood pressure, pulse), medications administered to the resident, or the residents transfer to the hospital.
A review of the MDS dated [DATE] documented in part, Discharge return anticipated. Discharge to acute hospital.
On 4/20/21 at 10:40 AM, during entrance conference, when asked what standards of practice were followed, ASM (administrative staff member) #2, the director of nursing and ASM #3, the quality consultant stated, We use [NAME] and [NAME] & Potter.
An interview was conducted on 4/22/21 at 4:56 PM with RN #2, the nurse supervisor. RN #2 was the second nurse who administered medications to Resident #47 on 7/2/20. When asked if she remembered the medication error on 7/2/20, RN #two stated, Oh yes, that was the error with the agency nurse who gave medicines and didn't chart, either time. I came to give the medications to the resident on my assignment sheet and since they were not signed off, I gave the 6:00 PM and 9:00 PM medications. I did not know we were both assigned to the resident until about 9:00 PM. If I had seen the medications signed off, I would have asked the other nurse about the assignment and the medications. I checked on the resident and saw that she did not look well, so I called the nurse practitioner and we transferred her to the hospital. When asked if staff should document events such as these and a hospital transfer in a progress note, RN #2 stated, Normally I would, I was so focused on getting the resident to the hospital and the medication error follow up, making sure the rest of the residents were cared for and our assignments were correct, I didn't write a progress note.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the lack of documentation concerns in the end of day conference on 4/22/21 at 5:15 PM.
According to Lippincott Nursing Procedures, Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Document information as soon as possible to ensure the accuracy of the information and to reflect ongoing care. Delayed documentation increases the potential for omissions, errors and inaccuracy due to memory lapse. (4)
No further information was provided prior to exit.
References:
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 71.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 137.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160.
(4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 52.
Based on clinical record reviews, facility document review and staff interviews it was determined that the facility failed to maintain a complete and accurate clinical record for eight of 25 residents in the current resident sample, Residents #44, #67, #25, #11, #80, #19, #24 and #47.
The findings include:
1. The facility staff failed to maintain a complete and accurate clinical record documenting treatments completed for Resident #44.
Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (1) and tracheostomy (2).
Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/12/21 coded Resident #44 as being non-verbal and severely impaired of making daily decisions. Section G coded Resident #44 as being totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependant on one staff member for eating and personal hygiene. Section M coded Resident #44 having one unstageable pressure ulcer (3).
The current physician order summary for Resident #44 documented in part,
- Body Audit- daily one time a day for skin observation. Order Date: 03/08/2021.
- Sacral (4) wound- cleanse with normal saline, pack with anasep (wound cleanser) and 4x4's (gauze), skin prep (liquid film-forming dressing) peri wound (around the wound), cover with dry protective dressing, cover with transparent dressings. Change daily and prn (as needed) until resolved or no longer indicated. Order Date: 03/29/2021.
- Cool air mist via trach collar (oxygen mask) continuous with O2 (oxygen) titrated in at 5 (five) liters every shift for respiratory failure (5). Order Date: 12/03/2020.
- L (left) plantar (sole of foot)- cleanse with normal saline, apply skin prep daily until resolved or otherwise indicated for change. Order Date: 03/03/2021.
- Suction every shift and as needed every shift for maintain patent (open) airway. Order Date: 12/03/2020.
- Trach care daily and PRN: For disposable: remove and dispose inner cannula. Replace with new inner cannula. One time a day for reduce risk of infection. Order Date: 12/03/2020.
The eTAR (electronic treatment administration record) dated 12/1/2020-12/31/2020 failed to evidence documentation for the following treatments on the following dates:
- Cool air mist via trach collar continuous with O2 titrated in at 5 liters every shift for respiratory failure. On 12/7/20 3:15p, 12/12/20 3:15p, 12/15/20 3:15p, 12/27/20 3:15p, 12/29/20 11:15(p).
- Suction every shift and as needed every shift for Maintain patent airway. On 12/7/20 3:15p, 12/12/20 3:15p, 12/15/20 3:15p, 12/27/20 3:15p, 12/29/20 11:15(p).
The eTAR (electronic treatment administration record) dated 1/1/2021-1/31/2021 failed to evidence documentation for the following treatments on the following dates:
- Sacrum- cleanse with wound cleanser, apply Calmoseptine, cover with foam dressing and prn every day shift. On 1/20/21 7:15a.
- Trach care daily and PRN . On 1/29/21 0900 (9:00 a.m.).
- Cool air mist via trach collar continuous with O2 titrated in at 5 liters every shift for respiratory failure. On 1/20/21 3:15p, 1/28/21 7:15a, 1/31/21 7:15a.
- Suction every shift and as needed every shift for Maintain patent airway. On 1/11/21 11:15(p), 1/20/21 3:15p, 1/28/21 7:15a.
The eTAR (electronic treatment administration record) dated 2/1/2021-2/28/2021 failed to evidence documentation for the following treatments on the following dates:
- Santyl ointment 250 unit/gm (unit per gram) (collagenase) Apply to sacrum topically every day shift for wound care. On 2/5/21 0900 (9:00 a.m.), 2/21/21 7:15a, 2/27/21 7:15a.
- Trach care daily and PRN . On 2/1/21 0900 (9:00 a.m.), 2/3/21 0900, 2/9/21 0900.
- Cool air mist via trach collar continuous with O2 titrated in at 5 liters every shift for respiratory failure. On 2/1/21 7:15a, 2/2/21 3:15p, 11:15(p), 2/3/21 7:15a, 2/9/21 7:15a.
- Suction every shift and as needed every shift for Maintain patent airway. On 2/1/21 7:15a, 2/2/21 3:15p, 2/3/21 7:15a, 2/9/21 7:15a, 2/20/21 11:15(p), 2/28/21 3:15p.
The eTAR (electronic treatment administration record) dated 3/1/2021-3/31/2021 failed to evidence documentation for the following treatments on the following dates:
- Body Audit- daily one time a day for skin observation. On 3/11/21 0900 (9:00 a.m.), 3/14/21 0900, 3/23/21 0900, 3/25/21 0900, 3/28/21 0900.
- L (left) plantar- cleanse with normal saline, apply skin prep daily until resolved or otherwise indicated for change . On 3/11/21 7:15a, 3/14/21 7:15a, 3/26/21 7:15a, 3/28/21 7:15a.
- Sacral wound- cleanse with normal saline, apply Santyl, pack with 4x4's, skin prep peri wound, cover with dry protective dressing, cover with transparent dressings. Change daily and prn until resolved or no longer indicated . On 3/11/21 7:15a, 3/14/21 7:15a, 3/24/21 7:15a, 3/26/21 7:15a, 3/27/21 7:15a, 3/28/21 7:15a.
- Santyl ointment 250 unit/gm (collagenase) Apply to sacrum topically every day shift for wound care. On 3/7/21 7:15a, 3/11/21 7:15a, 3/14/21 7:15a, 3/24/21 7:15a, 3/26/21 7:15a, 3/27/21 7:15a, 3/28/21 7:15a.
- Trach care daily and PRN . On 3/1/21 0900 (9:00 a.m.), 3/11/21 0900, 3/14/21 0900, 3/23/21 0900, 3/25/21 0900, 3/28/21 0900.
- Cool air mist via trach collar continuous with O2 titrated in at 5 liters every shift for respiratory failure. On 3/1/21 7:15a, 3/10/21 3:15p, 3/11/21 7:15a, 3/14/21 7:15a, 3/23/21 7:15a, 3/23/21 11:15(p), 3/25/21 7:15a, 3/28/21 7:15a, 3/28/21 3:15p.
- Suction every shift and as needed every shift for Maintain patent airway. On 3/1/21 7:15a, 3/10/21 3:15p, 3/11/21 7:15a, 3/14/21 7:15a, 3/23/21 7:15a, 3/25/21 7:15a, 3/28/21 7:15a, 3/28/21 3:15p.
The eTAR (electronic treatment administration record) dated 4/1/2021-4/30/2021 failed to evidence documentation for the following treatments on the following dates:
- Body Audit- daily one time a day for skin observation. On 4/11/21 0900 (9:00 a.m.).
- Anasept Antimicrobial Gel 0.057% Apply to sacral wound topically every day shift for wound . On 4/10/21 7:15a, 4/11/21 7:15a.
- L plantar- cleanse with normal saline, apply skin prep daily until resolved or otherwise indicated for change . On 4/11/21 7:15a.
- Sacral wound- cleanse with normal saline, pack with anasep and 4x4's, skin prep peri wound, cover with dry protective dressing, cover with transparent dressings. Change daily and prn until resolved or no longer indicated . On 4/10/21 7:15a, 4/11/21 7:15a.
- Trach care daily and PRN . On 4/11/21 0900 (9:00 a.m.).
- Cool air mist via trach collar continuous with O2 titrated in at 5 liters every shift for respiratory failure. On 4/4/21 11:15(p), 4/6/21 11:15(p), 4/11/21 7:15a, 11:15(p).
- Suction every shift and as needed every shift for Maintain patent airway. On 4/4/21 11:15(p), 4/6/21 11:15(p), 4/11/21 7:15a, 11:15(p).
On 4/21/21 at approximately 11:55 a.m., an interview was conducted with ASM (administrative staff member) #3. ASM #3 stated that the nurses signed off on the eTAR that wound care was completed and they documented by exception. ASM #3 stated that refusals of care were documented each occurrence. ASM #3 stated that the empty spaces on the eTARS would be a deficient practice but they could not say that the treatments were not done and that it was a failure to document.
On 4/22/21 at approximately 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that treatments were documented on the eTAR. LPN #8 stated that the documentation was evidence that the treatment was completed on that date and time. LPN #8 stated that if the eTAR was blank the treatment was not done.
On 4/22/21 at approximately 11:20 a.m., a request was made to ASM #1, ASM #2, ASM #3 and ASM #4 for additional documentation regarding Resident #44's pressure ulcer and for documentation of body audits completed, wound care, tracheostomy care, oxygen administration and suctioning completed from December 2020 through the present on the dates listed above. ASM #1, the administrator requested to have staff sign a written declaration that the treatments listed above were completed but not documented. ASM #1 was advised to have the responsible staff interview with surveyors regarding the dates that treatments were not documented.
On 4/22/21 at approximately 2:08 p.m., an interview was conducted with LPN #5. LPN #5 stated that when they had a wound nurse they provided treatment to the wound and when they were not there the nurse assigned to the resident provided the treatment. LPN #5 stated that treatments were documented on the eTAR and if the eTAR was blank the treatment was not done.
On 4/22/21 at approximately 5:00 p.m., a second interview was conducted with LPN #8. LPN #8 stated that the computers at the facility glitched frequently and they had provided the treatments to Resident #44's sacral wound each day Monday through Friday.
On 4/23/21 at approximately 9:17 a.m., an interview was conducted with LPN #1. LPN #1 stated that they provided treatments to Resident #44 on the days they were assigned to them and had forgotten to sign them off on the eTAR. LPN #1 stated that they also have computer glitches and treatments that they sign off on the eTAR do not always show as signed off. LPN #1 stated that they have problems with all of their laptops not saving the documentation on the eTARs.
On 4/23/21 at approximately 9:12 a.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that they provided treatments to Resident #44 on the days they were assigned to them and had forgotten to document them. RN #4 stated that they also have problems with the internet in the building and the laptops do not save their documentation on the eTARS at times.
On 4/23/21 at approximately 9:17 a.m., an interview was conducted with LPN #7. LPN #7 stated that they had provided treatments to Resident #44 on the days they were assigned to them and had forgotten to document them.
The facility policy Medication and Treatment Administration Guidelines dated 07/2006 .Updated 03/2018 documented in part, .Documentation: Medications and treatments administered are documented immediately following administration or per state specific standards .
The facility policy Focus on F Tag 842, undated, documented in part, .The medical record must contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions .
On 4/23/21 at approximately 10:05 a.m., ASM (administrative staff member) #1, ASM #2, the director of nursing and ASM #3, the quality consultant were made aware of the findings.
No further information was provided prior to exit.
Reference:
1. Intracerebral hemorrhage: Bleeding in the brain caused by the breaking (rupture) of a blood vessel in the head. This information was obtained from the website: http://pacificschoolserver.org/med/ency/article/000796.htm.
2. Tracheostomy: A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm.
3. Pressure ulcer are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000147.htm.
4. Sacral: The sacrum is a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis. The sacrum forms the posterior pelvic wall and strengthens and stabilizes the pelvis. Joined at the very end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx or tail bone. The coccyx provides slight support for the pelvic organs but actually is a bone of little use. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/19464.htm
5. Respiratory failure: When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.
2. For Resident # 67, the facility staff failed to document treatment administered for pressure injuries during March, April, and May of 2021.
Resident #67 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including ESRD (end stage renal disease) (2), diabetes (3), lymphedema (4), and bipolar disorder (5). The most recent MDS (minimum data set) assessment, an annual assessment with an ARD (assessment reference date) of 4/12/21, coded Resident #67 as coded as having no cognitive impairment for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). She was coded as having one stage 2 pressure injury, which was present on admission or re-entry.
Resident #67 refused to be interviewed regarding her pressure injuries.
On the following dates and times: 4/20/21 at 11:38 a.m., 4/20/21 at 12:40 p.m., 4/20/21 at 1:45 p.m., 4/21/21 at 9:11 a.m., and 4/21/21 at 2:46 p.m., Resident #67 was observed lying on her back in the bed. During all observations, Resident #67 was observed to be lying on a pressure-relieving mattress.
On 4/21/21 at 2:46, p.m., Resident #67's wound care was observed. RN #1 showed both feet and Resident #67's sacrum. No wounds were visible at this time.
A review of Resident #67's Braden Scale Assessment for risk of developing pressure injuries dated 3/3/21 revealed that she was at high risk, having scored 12.
Review of Resident #67's clinical record revealed the following orders, and the following dates for which the TAR (treatment administration record) contained no evidence that the treatments were administered according to the orders:
- 2/26/21: Sacral wound- Cleanse with NS. Apply calcium alginate
and foam dsg. daily. Every day shift for wound care. Not documented as administered 2/27/21, 3/2/21.
- 3/3/21: Sacral wound- Cleanse with NS. Apply Silvasorb to calcium alginate, apply to wound bed, cover with dry protective dressing. Change daily and prn (as needed) until resolved. Every day shift for skin alteration. Not documented as administered 3/7/21.
- 3/10/21: R heel - apply skin prep daily every day shift for skin alteration. Not documented as done 3/11/21, 3/15/21, 3/24/21, 3/27/21, 4/2/21, 4/10/21, 4/11/21, 4/17/21, and 4/19/21.
On 4/21/21 at 11:53 a.m., ASM (administrative staff member) #3, the quality consultant, ASM #1, the administrator, RN (registered nurse) #1, and ASM #2, the DON (director of nursing) were interviewed. When asked about the multiple instances of lack of documentation that treatments were completed for pressure injuries, she stated it would definitely be a deficient practice. She stated it would be a failure to document. She stated: We can't evidence it was done if it's not documented. She stated the DON and unit managers review the TARs, and are responsible for overseeing that treatments are getting done.
On 4/21/21 at 2:57 p.m., LPN (licensed practical nurse) #2 was interviewed. When asked if she took care of Resident #25, she stated she did. When shown the TARs for Resident #67 from February, March and April of 2021 and asked about the lack of evidence that pressure injury treatments were done, LPN #2 stated If there is a hole or a blank, it was note done. A medication or a treatment.
On 4/22/21 at 11:31 a.m., ASM #3, ASM #1, and ASM #2 were informed of the multiple instances in Resident #67's TARs where pressure injury treatments were not documented as done.
On 4/22//21 at 1:41 p.m., LPN #5 was interviewed. She stated after she completes a pressure injury treatment, she signs it on the TAR. When asked what can be said about a treatment if there is blank on the TAR where a nurse signature should be, she stated: It was not done.
On 4/22/21 at 4:18 p.m., LPN #2 returned to request another interview with the survey team. She stated she had been thinking about something she had said during the previous day's conversation, and wanted to clarify. She stated if there is a hole in the MAR or TAR, the treatment could have been done. She stated the staff may have gotten pulled away for an urgent event like a resident's fall. LPN #2 stated, If it's not signed, it may have been done. LPN #2 stated: Some things, I can tell you I did. Some t[TRUNCATED]
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 4 harm violation(s), $73,788 in fines. Review inspection reports carefully.
- • 109 deficiencies on record, including 4 serious (caused harm) violations. Ask about corrective actions taken.
- • $73,788 in fines. Extremely high, among the most fined facilities in Virginia. Major compliance failures.
- • Grade F (5/100). Below average facility with significant concerns.
Bottom line: Trust Score of 5/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Rosedale Health & Rehabilitation's CMS Rating?
CMS assigns ROSEDALE HEALTH & REHABILITATION an overall rating of 1 out of 5 stars, which is considered much 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 Rosedale Health & Rehabilitation Staffed?
CMS rates ROSEDALE HEALTH & REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 66%, which is 20 percentage points above the Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Rosedale Health & Rehabilitation?
State health inspectors documented 109 deficiencies at ROSEDALE HEALTH & REHABILITATION during 2021 to 2025. These included: 4 that caused actual resident harm, 103 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Rosedale Health & Rehabilitation?
ROSEDALE HEALTH & REHABILITATION 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 HILL VALLEY HEALTHCARE, a chain that manages multiple nursing homes. With 128 certified beds and approximately 120 residents (about 94% occupancy), it is a mid-sized facility located in RICHMOND, Virginia.
How Does Rosedale Health & Rehabilitation Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, ROSEDALE HEALTH & REHABILITATION's overall rating (1 stars) is below the state average of 3.0, staff turnover (66%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Rosedale Health & Rehabilitation?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Rosedale Health & Rehabilitation Safe?
Based on CMS inspection data, ROSEDALE HEALTH & REHABILITATION 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 1-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 Rosedale Health & Rehabilitation Stick Around?
Staff turnover at ROSEDALE HEALTH & REHABILITATION is high. At 66%, the facility is 20 percentage points above the Virginia average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Rosedale Health & Rehabilitation Ever Fined?
ROSEDALE HEALTH & REHABILITATION has been fined $73,788 across 1 penalty action. This is above the Virginia average of $33,817. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Rosedale Health & Rehabilitation on Any Federal Watch List?
ROSEDALE HEALTH & REHABILITATION 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.