cms_WV: 3869
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3869 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 353 | E | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs and in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. The facility failed to implement Resident #78's diabetes management (finger sticks and sliding scale insulin) for twenty-five (25) days after the resident's admission, failed to obtain an ordered basic metabolic panel (BMP), failed to ensure the resident kept an appointment scheduled with a consulting physician ([MEDICATION NAME]), and failed to administer/hold an antihypertensive ([MEDICATION NAME]) according to the physician ordered parameters. For Resident #9, the facility failed to ensure arrangements were provided for two (2) appointments with consulting physicians, failed to administer [MEDICATION NAME] (steroid) as directed for the treatment if exacerbation of [MEDICAL CONDITIONS], and failed to notify the physician when the resident's blood sugars were outside of the physician ordered parameters. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. For Resident #27, the facility failed to ensure the assessed lift, transfer and positioning assessment correlated with the resident's care plan to ensure staff knew how to safely transfer the resident. For Resident #69, the facility failed to follow the physician ordered parameters for insulin and the nursing staff held the resident's insulin without orders. For Residents #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, and #15, nurses failed to document medications immediately after administration. These practices had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, #15, #9, #10, #27, and #69. Facility census: 62. Findings include: a) Record review, policy review, and staff interview, the facility failed to provide services according to accepted standards of clinical practice in regards to medication administration for 39 of 62 residents currently residing in the facility. Two (2) Licensed Practical Nurses (LPN) administering evening and bedtime medications did not sign their names on the medication administration record (MAR), as the medication was being given as per accepted standards of clinical practice and facility policy. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, and #15. On 01/18/17 at 9:30 p.m., the facility was entered to observe evening shift's medication pass. LPN #94 and LPN #95 said all of their medications had been given and there were not any medication passes to be observed at that time. LPN #94 was requested to provide medication administration records (MAR) for residents randomly chosen for review. Upon asking for the MAR for Resident #54, LPN #94 stated she had not yet passed the medications to Resident #54. LPN #94 was told when she did give Resident #54's medications, the surveyor would use that opportunity to observe the medication pass for Resident #54. At 10:04 p.m., while preparing to do the medication pass for Resident #54, LPN #94 said she had not yet signed off on any of the medications she had administered that evening. LPN #94 stated she had started giving medications at 7:00 p.m. and had yet to sign off on any of the medications given. When LPN #94 was asked, When should you sign off on medications? she stated, When I give them, I should sign off and document that they are given as soon as I give them. On 01/18/17 at 10:10 p.m., LPN #95 was asked her if she had signed off on the medications she had given that evening. LPN #95 stated she had not signed the EMAR (electronic medication administration records) at the time the medications were given, and that she was signing off on some of them now. A list of resident's names that had been given medications without LPN #95 signing at the time of dispensing was requested. On 01/18/17 at 10:25 p.m., an interview with the recently acting interim director of nurses, Registered Nurse (RN #109), revealed LPN #95 was a recent hire and LPN #94 had done some training of LPN #95. RN #109 confirmed facility policy and standard of practice dictate nurses sign the EMAR at the time medications are given. The RN verified that not documenting in the EMAR at the time the medications were given would cause the record to be inaccurate for the time the residents received their medication. RN #109 stated disciplinary actions would be taken for both LPN #94 and LPN #95. A list of all residents that had evening and bedtime medications given by LPN #94 and LPN #95, and whose MARs had not been signed by LPN #94 and LPN #95 at the time the medications were given to the residents, was requested. The requested list of residents' names provided on 01/18/17 at 11:03 p.m., revealed LPN #94 gave medications to twenty-nine (29) residents without documenting medications had been given in the EMAR (electronic medication administration record) at the time they were given. LPN #95 gave medications to ten (10) residents without documenting medications had been given in the EMAR at the time they were given. On 01/18/17 at 11:11 p.m., a walk through of the facility to interview any residents identified on the list that might still be awake found Residents #20, #21, and #89 were awake. All three (3) residents stated they did receive their evening and bed time medications. On 01/19/17 at 8:04 a.m., review of facility's policy 6.0 'General Dose Preparation and Medication Administration revealed, #6. After medication administration, facility staff should take all measures required by Facility policy and Applicable Law, including but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given .) on appropriate forms. According to Lippincott's 2012 Nursing Drug Handbook, Rights of Medication Administration the 8 rights of medication administration are: 1. Right patient . 2. Right medication . 3. Right dose . 4. Right route . 5. Right time - Check the frequency of the ordered medication. - Double-check that you are giving the ordered dose at the correct time. - Confirm when the last dose was given. 6. Right documentation - Document administration AFTER giving the ordered medication. - Chart the time, route, and any other specific information as necessary. 7. Right reason ., 8. Right response . b) Medical record review, staff interview, and resident interview, revealed the facility failed to implement Resident #78's physician's orders [REDACTED]. For Resident #9, the facility failed to ensure arrangements were provided for two appointments with consulting physicians (psychiatrist and urologist), failed to administer [MEDICATION NAME] (steroid) as directed for the treatment of [REDACTED]. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. The physician ordered the supplement to be given three (3) times a day, but the facility only administered it twice daily. For Resident #27, the facility failed to establish a care plan based on the resident's assessed needs for transfers. For Resident #69, the facility failed to follow the physician's parameters for insulin and the nursing staff held the resident's insulin without physician input. 1. Resident #78 a. Review of Resident #78 medical records on 01/18/17 at 10:00 a.m. found this seventy-seven (77) year old female was admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. Discharge instructions from the acute care facility and approved by the attending physician at the facility included: Finger sticks before meals and night (four times daily) for thirty (30) days and administer sliding scale insulin using [MEDICATION NAME] Regular insulin PRN (as needed) as follows: -- less than 150 - no insulin -- 151-200 - 2 units of insulin -- 201-250 - 4 units of insulin -- 251-300 - 6 units of insulin -- 301-350 - 8 units of insulin -- greater than 350 - give 10 units of insulin and call the physician Review of the resident's Medication Administration Record (MAR) for (MONTH) (YEAR), found the finger sticks and sliding scale were not completed from 08/03/16 through 08/25/16. b. On 08/25/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 350. Further review of the MAR and nurses' notes for (MONTH) (YEAR) found the resident's blood sugar was 377 at 6:00 a.m. on 08/28/16. There was no evidence the physician was notified. On 08/29/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 400. Review of MAR and nurse's notes for (MONTH) and (MONTH) (YEAR), found: -- on 09/04/16 at 6:00 a.m. blood sugar was 430, -- on 09/11/16 at 6:00 a.m. blood sugar 400, and -- on 09/05/16 at 4:00 p.m. blood sugar 423. The record contained no evidence the physician was notified. c. The physician ordered a complete blood count (CBC), basic metabolic panel (BMP) and [MEDICATION NAME] time/international ratio (PT/INR) in two days (08/05/16) then as directed by the facility physician. Record review found no evidence the BMP was obtained on 08/05/16 d. Review of the resident's medical record found an appointment with ([MEDICATION NAME]'s Name) on 08/16/16 at 12:15 p.m. was not attended. e. [MEDICATION NAME] (antihypertension medication) 12.5 milligrams (mg) through feeding tube twice daily. Hold if systolic blood pressure (b/p) is less than 110 or if heart rate/pulse less than 70. Review of the MAR for August, September, October, November, and (MONTH) (YEAR) and (MONTH) (YEAR) found the following the following issues: -- 08/03/16 at 10:00 p.m. - no pulse obtained -- 08/04/16 at 10:00 a.m. and 10:00 p.m. - no pulses obtained -- 08/05/16 at 10:00 p.m. pulse 98- [MEDICATION NAME] not given -- 08/11/16 at 10:00 p.m. pulse 84-[MEDICATION NAME] not given -- 08/16/16 at 10:00 p.m. - no blood pressure obtained -- 08/18/16 at 10:00 p.m. - no blood pressure obtained -- 08/26/16 at 10:00 p.m. - no blood pressure obtained -- 08/30/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 08/31/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 09/01/16 through 09/15/16 at 9:00 a.m. no pulses obtained (total of 15 days) -- 11/18/16 at 9:00 a.m. - Pulse 68- medication given -- 11/23/16 at 9:00 p.m. - Pulse 68- medication given -- 11/24/16 at 9:00 a.m. - Pulse 68- medication given -- 11/24/16 at 9:00 p.m. - Pulse 66- medication given -- 11/25/16 at 9:00 p.m. - Pulse 68- medication given -- 11/28/16 at 9:00 p.m. - Pulse 68- medication given -- 12/02/16 at 9:00 p.m. - Pulse 68- medication given -- 12/06/16 at 9:00 p.m. - No pulse- medication given -- 12/20/16 at 9:00 p.m. - Pulse 68- medication given -- 12/24/16 at 9:00 p.m. - Pulse 68- medication given -- 01/14/17 at 9:00 a.m. - Pulse 68- medication given f. During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the former director of nursing (DON), the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., the following were reviewed/discussed: -- The resident's medical records, since admission on 08/03/16 through 08/25/16, did not contain evidence of finger sticks with sliding scale coverage as ordered. -- It was confirmed on 08/28/16, 09/04/16, 09/05/16, and 09/11/16, the physician was not notified of blood sugars above the physician-established parameters. -- It was verified Resident #78 was not sent to the scheduled appointment with the [MEDICATION NAME] -- A BMP was not obtained on 08/05/16 as ordered -- Review of the blood pressures and pulses for the physician prescribed parameters were not obtained and/or the medication was not held or not given according to the physician-established parameters. 2. Resident #9 Review of Resident #9's medical records on 01/18/17 at 2:00 p.m., found this eighty-six (86) year old female, admitted to the facility on [DATE] from an acute care hospital, had [DIAGNOSES REDACTED]. a. Discharge instructions from the acute care facility and approved by her attending physician at the facility included appointments with a psychiatrist in two (2) to three (3) weeks for follow-up for major [MEDICAL CONDITION] and with a urologist in four (4) weeks for retention of urine and recurrent urinary tract infections. b. Review of physician's orders [REDACTED]. This was ordered for an exacerbation of the resident's [MEDICAL CONDITION]. The [MEDICATION NAME] was started on 12/23/16 and the resident was given 40 mg on 12/23/16, 12/24/16, and 12/25/16 at 9:00 a.m. On 12/26/16, Resident #9 should have received [MEDICATION NAME] 30 mg, but did not receive that dose until 12/27/16. c. Review of the physician's orders [REDACTED]. Call the doctor if blood sugar is less than 60 or if blood sugar greater than 350. Review of the (MONTH) and (MONTH) (YEAR) MARs and nurses' notes revealed: -- 12/17/16 at 4:30 p.m. - blood sugar 372 - no notification of doctor -- 12/24/16 at 6:00 a.m. - blood sugar 376 - no notification of doctor -- 12/25/16 at 4:30 p.m. - blood sugar 398 - no notification of doctor During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the previous director of nursing) (DON), RN #110, the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., review of Resident #9's medical records verified: -- the facility failed to schedule the appointments as directed, -- Resident #9 missed a dose of [MEDICATION NAME] on 12/26/16, and -- Resident #9's blood sugar was outside of the physician-established parameters and the physician was not notified. 3. Resident #10 A review of Resident #10's medical record at 10:22 a.m. on 01/17/16 found a physician's orders [REDACTED]. Review of the electronic system used by the Nurse Aides to document supplement percentages and other care provide to a resident, revealed the percentage of the Nepro Resident #10 consumed in the last 14 days (from 01/04/17 through 01/17/17) was only documented twice (2) daily. An interview with Registered Nurse (RN) #109 at 3:57 p.m. on 01/18/17 confirmed the supplement was documented in the record as given twice daily instead of three times daily as ordered by the physician. RN #109 then reviewed the resident's Medication Administration Record and confirmed it was not documented there either. She confirmed that according to the documentation Resident #10 only received her Nepro supplement two (2) times a day instead of the ordered three (3) times a day. 4. Resident #27 A review of Resident #27's medical record at 9:25 a.m. on 01/19/17 found a Lift/Transfer Tool completed by Licensed Practical Nurse (LPN) #68 on 10/19/16. The facility used the Lift/Transfer Tool to assesses how a resident should be transferred from surface to surface i.e. bed to chair and/or chair to bed safely. The tool identified five (5) lift options the assessor could select based on the accurate completion of the assessment of Resident #27's ability's and condition. The 5 options were: -- No lift needed. (Suggest use of gait belt.) -- Sit to stand Lift is required. -- Total Lift required. -- Transfer requires assist of 2 (two) staff with use of gait belt. -- Consult Therapy Services to determine transfer assist level. Review of the Lift/Transfer tool completed by LPN #68 for Resident #27 found the LPN had chosen three (3) options for safe transfer for Resident #27: -- No lift needed (Suggest use of gait belt.) -- Sit to Stand lift is required. -- Transfer requires assist of 2 staff with the use of gait belt. Review of Resident #27's care plan found Resident #27 was to be transferred with the assistance of one (1) staff member. The care plan did not mention the use of a gait belt or the use of a sit to stand lift. An interview with RN #109 and Corporate RN #108 at 11:33 a.m. on 01/19/2017, confirmed the lift transfer tool for Resident #27 was not completed correctly; therefore it did not fulfill its intended purpose of telling staff how Resident #27 should be transferred. They agreed the form was not clear on how the resident should have been transferred during her stay and therefore one could not be certain if the one person assist for transfers identified on the care plan was the correct and safest way to transfer Resident #27. 5. Resident #69 During Stage 1 of the Quality Indicator Survey (QIS), the resident said he was worried the facility was, Going to kill me with insulin. He said the nurses came into his room to give his insulin and they had not even taken his blood sugar first. They can't give me insulin if they don't check my blood sugar first, just think what could happen if I didn't ask them. The resident, admitted to the facility on [DATE], had capacity to make medical decisions. Review of the current physician's orders [REDACTED]. The parameters specified to contact the physician if the blood sugar (BS) was less than 60 or greater than 400. Review of the medication administration record (MAR) for (MONTH) (YEAR) found the resident was receiving the following insulins for treatment of [REDACTED].>-- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 6 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 25 unit subcutaneously at bedtime for diabetes mellitus. In (MONTH) (YEAR), the resident was to receive: -- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 10 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 35 unit subcutaneously at bedtime for diabetes mellitus. The MAR for (MONTH) (YEAR) noted the resident's [MEDICATION NAME] remained the same, but the [MEDICATION NAME] 100 units/ml was increased to 12 units on 01/12/17. At 9:47 a.m. on 01/18/17, the resident's MARs for 08/03/16 through 01/18/17 were reviewed with the Corporate Registered Nurse (RN #108) and RN #109 (the former acting director of nursing). The review identified the following: -- On 08/19/16, 08/21/16, 08/30/16, and 08/31/16, the nurse initialed and circled the resident's 6:00 a.m. dose of [MEDICATION NAME] solution. RN #108 verified the nurses' initials that were circled, indicated the medication was not given. -- On 10/20/16, the nurse again initialed and circled the resident's 8:15 a.m. dose of [MEDICATION NAME]. -- On 01/15/17 at 9:53 a.m., a nurse wrote a progress note indicating the resident's [MEDICATION NAME] solution was held due to a low blood sugar and at the request of the resident. RN #108 and RN #109 verified the insulin could not be held without physician's orders [REDACTED]. -- In addition, the resident's blood sugar was 53 on 08/19/16 at 6:00 a.m. There was no evidence the physician was contacted per the parameters specified with the accuchecks. -- Review of the MARs from 08/03/16 through 01/18/17 found the facility obtained the resident's blood sugars at 6:00 a.m. and 5:00 p.m. The physician's orders [REDACTED]. The resident received three (3) meals a day, meaning the resident's blood sugars should have been completed four (4) times a day, not two (2). b) Record review and staff interview revealed the facility failed to ensure complications from Resident #61's feeding tube were minimized by providing the correct type, rate, and volume of the feeding as ordered by the resident's attending physician. Resident #61 was not given the correct bolus feedings from 12/11/16 through 01/10/17. 1. A review of Resident #61's medical record found the following nutrition/weight progress note written by the facility's registered dietitian (RD): -- RD note dated 12/09/16 (typed as written): RD TF (tube feeding) note. Diet; Reg. (regular) pureed. PO (by mouth) intake past week 51 - 75% X (symbol for times) 3 (three) meals and 76-100% X 3 days. Adequate po intake. TF: Glucerna 1.2 1 (one) can 2 (two) X day w/ (with) 120 cc (cubic centimeter) flush bid (twice a day) = (symbol for equals) 570 kcal (kilocalorie), 28.4 gm (grams) prot. (protein), 384 cc free fluid, 624 cc w/ flushes. Wt. (weight) history: 12/9 (2016) 149# (pounds), 11/2 (2016) 156.8#, 6/3 (2016) 155.8# - wt. loss trend x 1, 3, and 6 months. Rec. (Recommend) TF - Glucerna 1.5 bolus 1 can 2 X a day w/ 120 cc flush bid to provide 712 kcal, 39 gm prot., 360 cc free fluid, 600 cc w/ current flushes. Weekly wts. (weights) x 4. Will fup (follow up) prn (as needed). Further review of the medical record found on 12/11/16 Resident #61 began receiving Glucerna 1.5 one (1) can two (2) times daily as recommended by the RD. However, upon further review of the Medication Administration Record (MAR) it was discovered Resident #61 continued to receive Glucerna 1.2 one (1) can two (2) times a daily as previously ordered. According, to the MAR, Resident #61 received one (1) can of Glucerna 1.2 and one (1) can of Glucerna 1.5 twice daily at 9:00 a.m. and 9:00 p.m. beginning on 12/11/16 through 01/07/17, when he should have only received one (1) can of Glucerna 1.5 two (2) times daily at 9:00 a.m. and 9:00 p.m. Further review of the record found the following general progress note dated 01/08/17 (typed as written): Note Text: Dietician emailed about weight loss, but no response yet I called her. (Name of RD) ordered to increase tube feeding to three cans per day. I called and spoke to resident's poa (power of attorney), (name and relationship of POA), and she is in agreement with the change to his P[NAME] (Plan Of Care). (Name of attending physician) asked the dietician to initiate and changes on Friday. Order initiated. Additional review of the MAR found Resident #61 stopped receiving Glucerna 1.2 one (1) can two (2) times daily on 01/08/17 and began receiving Glucerna 1.2 one (1) can three (3) times daily as recommended by the RD on 01/08/17. He began receiving the Glucerna 1.2 three (3) times daily via is feeding tube at 8:00 a.m., 12:00 p.m. and 5:30 p.m. daily. He received this for the first time on 01/08/17 at 5:30 p.m. However; the MAR indicated Resident #61 continued to receive Glucerna 1.5 one (1) can two (2) times daily at 9:00 a.m. and 9:00 p.m. until 01/10/17 after the 9:00 a.m. administration. The Glucerna 1.5 should have been discontinued upon the starting of the Glucerna 1.2 three (3) times daily. He received the Glucerna 1.5 at 9:00 p.m. on 01/08/17, at 9:00 a.m. and 9:00 p.m. on 01/09/17, and at 9:00 a.m. on 01/10/17 when he should not have received it. These findings were reviewed with Registered Nurse (RN) #109 and Corporate RN #108 at 9:22 a.m. on 01/18/17. They confirmed from 12/11/16 through 01/10/17, Resident #61 did not receive the correct enteral feeding as recommended by the RD and ordered by the attending physician. 2. Record review, staff interview, and observation, revealed the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. Staff did not consistently implement planned interventions across all shifts to help prevent Resident #61 from falling. A review of Resident #61's medical record at 2:17 p.m. on 01/17/17 found he had the following falls within the last 30 days: -- 12/23/16 at 4:00 a.m. - Resident #61 was found sitting on the floor beside his bed and reported he was trying to go to the bathroom. -- 01/13/17 at 2:30 a.m. - Resident was laying on floor beside his bed. He stated that he was trying to go to the bathroom. -- 01/14/17 at 5:30 a.m. - Resident was found lying on the floor. The resident's pants were down and there was feces on the floor. The resident was unable to state what he was trying to do when he fell . -- 01/16/17 at 6:45 a.m. - The resident was found sitting on the floor with his back against the bed. The resident was again unable to tell the staff what happened. A review of Resident #61's care plan found a focus statement (typed as written): Potential for falls related to HX (history of) falls with fracture which is complicated by [MEDICAL CONDITION], muscle weakness and other multiple medical problems. Resident is able to ambulate (walk) independently about the facility. This focus statement was initiated on 09/12/14 with a revision date of 01/05/17. The goal associated with this focus statement was, Resident will have no falls with injury such as fracture, dislocation, head trauma or any injury requiring hospitalization through next review. This goal had an initiation date of 09/12/14 with a revision date of 09/08/16 and a target date of 04/06/17. The interventions associated with this focus statement and goal included: -- Ensure resident is wearing non-skid socks while in bed and non-skid shoes when ambulating or transferring. This was added as an intervention on 02/27/15 with a revision date of 05/20/16. -- Nurse to turn on night light at bedside at 9:00 p.m. to help prevent falls. This was added as an intervention on 12/31/16. During an interview with Registered Nurse (RN) #109 at 4:06 p.m. on 01/18/17, when asked what interventions were put into place to help prevent Resident #61 from falling, she stated, He has a night light at his bedside that we turn on at night. She also confirmed the care plan indicated that he should be wearing non-skid socks while in bed and non-skid shoes when ambulating or transferring. At 4:10 p.m. on 01/18/17, the Director of Nursing and RN #109 were present for observations of Resident #61. The resident was lying on his bed, but was not wearing non-skid socks. A battery operated a night light sat on his window sill. After completion of the observation, RN #109 confirmed he was not wearing non-skid socks. She stated, He had his shoes on before he laid down. During an interview with Licensed Practical Nurse (LPN) #95 at 9:46 p.m. on 01/18/17, she stated she was Resident #61's nurse and would be until 6:00 a.m. the following morning. When asked what interventions Resident #61 had in place related to his falls she stated, He has a low bed and a fall mat I think. (Please note neither of these things were an intervention for Resident #61.) When asked how she would know what new interventions a resident had if they were added when she was not there, she stated, They pass that along to us verbally during report. She stated, If we really need to, we can always look at the physician's orders [REDACTED].#95 did not mention looking at Resident #61's care plan for any fall interventions. Observations of Resident #61's room at 10:00 p.m. on 01/18/17 found the room dark. The overhead lights were turned off and the night light sitting in the window sill was not turned on as directed in the care plan. At 10:28 p.m. on 01/18/17, RN #109 was asked to observe Resident #61's room. She confirmed the resident's night light was not on and should have been. She promptly entered the room and turned on the light. c) Observation, record review, and staff interview, the facility failed to ensure a resident received a therapeutic diet for weight loss. In addition, monitoring and evaluation of the effectiveness of the interventions added for weight loss did not occur due to inaccurate documentation of the amount consumed by the resident. 1. Resident #35 During Stage 2 of the Quality Indicator Survey (QIS), the resident was selected for review due to a weight loss. Record review found the resident's weight was 120.9# (pounds) on 11/02/16. On 11/23/16, the resident was discharged to the hospital. She returned to the facility on [DATE] at which time her recorded weight was 113.4# on 11/25/16. The facility acknowledged the resident's weight loss on 11/29/16. The physician was contacted and did not add any interventions as the resident was already receiving house shakes. Review of the physician's orders [REDACTED]. The resident's weight was 110.5# on 01/02/17, 111.4# on 01/06/17, and 111# on 01/10/17. On 01/9/17, the dietary manager recorded the following note: This is a dietary note on (name of resident) for her quarterly review of 1/2/17. (Name of resident) has had a 10.4# weight loss during the review of this quarter which is 8.6%. Her current weight is 110.5 and she is eating 51-75% of all meals. She eats in the Atrium room and is receiving a house shake BID (two times a day). On 12/01/16, the registered dietitian saw the resident. The dietitian noted the weight loss and documented the resident had a weight gain in the past week and weight could fluctuate due to the use of a diuretic. The resident's weight was 117# on 12/01/16. House shakes were to continue. On 01/11/17, the dietitian saw the resident and ordered 1 fortified food item per tray, 8 ounces of whole milk, and ice cream with lunch and dinner. At 11:55 a.m. on 01/17/17, the resident was eating her noon meal in the Atrium with her daughter. A carton of fat free milk was on the resident's tray. At 12:05 p.m. on 01/17/17, Assistant Food Services Director #3 verified the resident did not receive 8 ounces of whole milk as ordered by the dietitian. Observation of the resident at 2:20 p.m. on 01/17/17 found she her sleeping in bed. The resident's house shake was sitting on bedside stand. The carton was open and contained a straw, but was full. At 3:15 p.m. on 01/17/17, the same house shake was still sitting on the resident's bedside table. The carton remained full. According to the information recorded in the computer, the resident consumed 100% of the house shake at 2:52 p.m. on 01/17/17.<b (TRUNCATED) | 2020-04-01 |