CMS-Nursing-Home-Full-Deficiencies

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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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
101	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	684	D	1	0	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, and policy review, the provider failed to ensure necessary care and services was provided for two of twelve sampled residents (52 and 56) as evidenced by: Not giving a timely opportunity to use a toilet or commode and not having a repositioning schedule in place to prevent decline for resident 52. Not investigating a skin tear of unknown origin and not providing an ordered as needed treatment to a swollen surgical site for resident 56. Findings include:1. Observation on 5/22/19 at 1:14 p.m. of resident 52 in her room revealed:She was alone in her room sitting in her wheel chair (w/c) with her back to the door. There was an over bed table in front of her with her lunch on it.There was a large wet area on the floor behind her w/c that was yellow colored.There was a bubble cup on the floor.She had gray sweat pants on.Those sweat pants were wet between her legs where she was sitting.The left front hip crease area of her sweat pants were also wet.Observation and interview on 5/22/19 at 1:18 p.m. of resident 52 in her room revealed:Certified nurse aide (CNA) M walked into the room.She noticed the wet area on the floor and to the resident's sweat pants.She stated she had offered to lay her down at approximately 10:00 a.m. so she could change her brief.-The resident had refused.She used her Walkie Talkie to ask for assistance to the room.She left and returned with a mop and bucket.She mopped up the wet area on the floor behind her w/c.She picked the bubble cup up from the floor and put it on her overbed table.She went into the bathroom and without washing her hands she put on gloves.Observation and Interview on 5/22/19 at 1:34 p.m. of resident 52 in her room revealed:CNAs H and I entered the room.CNA I stated that he and another CNA had changed the resident's brief at 11:50 a.m.-She had had a bowel movement (BM).-When asked, CNA I stated that he had documented that brief change.CNA H states:-They check on her every two hours.-They do not have the correct Hoyer sling to take her to the toilet or put her on a commode.-She is a Hoyer lift so there is no way to toilet her.Both CNAs I and M agree with CNA H's above statements.At 1:38 p.m. CNA M removes her gloves.-Did not perform hand hygiene.-Left the room.Observation on 5/22/19 at 1:39 p.m. of resident 52 reveals:CNAs H and I have used the Hoyer lift to lay her on her bed.They performed a brief change.They changed her linens.They put her into dry clothes.They put her into a clean and dry w/c.-Her over-the-bed table with her lunch and bubble cups was placed in front of her.Both CNAs leave the room.Observation on 5/22/19 at 2:13 p.m. of resident 52 reveals:She is sitting in her w/c with her back to the door.Her over-the bed table with her lunch tray and three bubble cups were on that table.One bubble cup was empty.Observation on 5/22/19 of resident 52 in her room revealed:At 2:22 p.m., 3:32 p.m., and 3:55 p.m. she was alone in her room.-She was in her w/c.-The television was on.-Her over-the-bed table and lunch tray were in front of her.-She was asleep.Observation on 5/22/19 at 4:20 p.m. of resident 52 in her room revealed:She was in the same position as above.Her lunch tray had been removed.Her over-the-bed table was in front of her.Observation on 5/22/19 at 4:48 p.m., 5:02 p.m., 5:46 p.m., 6:22 p.m., and 6:30 p.m., of resident 52 in her room revealed:She was in the same position as above.Between 2:13 p.m. and 6:30 p.m., there had been no observation of anyone:Entering or leaving her room.Changing her brief.Repositioning her.Interview on 5/23/19 at 8:39 a.m. with the director of nursing concerning resident 52 revealed:We implement a turn and repositioning every two hours:-While in bed.-While in a w/c.She is a heavy wetter.They should be checking her brief at least every hour.They should be repositioning her at least every two hours.She is a Hoyer lift.They should be offering her a bedpan or toileting her.-I am unaware the staff is just allowing her to urinate and have BM's in her brief.She does not have the mental capacity to make a decisionI am not sure she would be able to hold herself up on a commode.Interview on 5/23/19 at 9:00 a.m. with the administrator concerning resident 52 revealed:She agreed the resident is not to be left alone in her room in her w/c.There was no documentation to prove that she had been toileted or repositioned every two hours.Interview on 5/23/19 at 12:40 p.m. with the administrator revealed:Everyone should be toileted or be asked if they need a bedpan.Resident's should be toileted every two hours and as needed.They should not be told or allowed to:-Urinate in their brief.-Have a BM in their brief.-And then be changed in place of toileting, unless they have refused toileting or a bedpan.There is no specific toileting schedule for a resident that wears briefs and is a Hoyer lift. Record review of the CNAs 5/22/19 continence and BM task documentation revealed:At 3:40 a.m. she was incontinent and had no BM.At 1:49 p.m. and 1:50 p.m. she was incontinent and had a medium BM.There was no documentation that at 10:00 a.m. the resident refused a brief change as CNA M stated at 1:18 p.m. above.There was no documentation that at 11:50 a.m. a brief change had been done as CNA I had stated at 1:34 p.m. above. 2. Observation and interview on 5/21/19 at 1:40 p.m. of LPN J while she completed wound care for the resident revealed: LPN J stated:-Resident 56's (surgical area) looks quite swollen today. --She did not provide ice for the surgical site even though there had been an order dated 5/2/19 that stated (MONTH) ice swollen area on (surgical site) for no more that 20 minutes per hour as needed for wound care. -She had been unsure of what happened to the resident's left forearm where there had been a two inch [MEDICATION NAME] gentle dressing in place. --The first treatment for [REDACTED]. --A skilled progress note on 5/7/19 stated Resident has a skin tear to right forearm, dressing CDI, (clean, dry, intact) to be changed every 3 days or PRN. --She could not identify any additional nursing progress notes or reports related to the skin tear on the resident's left arm. Interview on 5/23/19 at 10:45 a.m. with the DON regarding resident 56's swollen surgical site and skin tear on her right forearm confirmed: The ordered treatment of [REDACTED]. The skin tear on her right forearm should have been documented in the progress notes and investigated on 5/6/19 by the identifying nurse . Review of the provider's Qtr 3, (YEAR) Abuse and Neglect Clinical Protocol revealed: Assessment and Recognition; The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment. Review of the providers Director of Nursing job description revealed: The Director of Nursing provides leadership, organization, planning, direction and administration of services toward the delivery of optimum resident care that is consistent with the established standards of nursing practice and the goals for a skilled nursing facility as part of the organization as a while. Also, provides information and assistance to Administration regarding nursing related issues; ensures the delivery services and programs continues to respond to the needs of the residents while contributing to the financial stability of the facility. *Plans, organizes, directs and supervises the delivery of nursing care activities provided to the residents; directly or through delegation; in accordance with organizational goals, federal and state requirements, and other professional standards, to ensure quality and continuity or nursing/medical services.	2020-09-01
102	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	686	H	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to identify and implement individualized interventions to prevent: Facility acquired pressure ulcers from developing for five of five sampled residents (9, 32, 45, 56, and 73). A blister from worsening and becoming a pressure ulcer for one of one sampled resident (62). Findings include: 1. Review of resident 9's medical record revealed: She had been admitted on [DATE]. Her Brief Interview of Mental Status (BIMS) score was three indicating she had severe cognitive impairment. She had been admitted with a right wrist splint and right knee immobilizer. Review of resident 9's skin assessments between 1/15/19 and 5/21/19 revealed on: 1/15/19 she was admitted with a stage three pressure ulcer on her right buttock and a blister on her right rear thigh. 1/29/19 both were healed. 1/30/19 three wounds had been identified: -Unstageable pressure ulcer between right thumb and fore finger. -Stage two blister to the right upper thumb area. -Suspected deep tissue injury to the right lower thumb. 2/5/19 two additional pressure ulcers were identified on her right hand: -Outside of the right little finger. -Back of the right hand. 2/12/19 two additional pressure ulcers were identified on her right outer ankle. -One stage one. -One stage two. 2/19/19 a stage two pressure ulcer was identified on her right inner heel. 2/26/19 all the above pressure injuries were healed. 4/30/19 a stage two pressure ulcer was identified on her left buttock. 5/7/19 Area to left buttock is bigger. Resident has cushion to w/c (wheelchair). Is working with therapy so doesn't always get laid down. 5/14/19 she had completed wound care and an unstagable wound was found on her coccyx. 5/21/19 two new suspected deep tissue injuries were identified. -Left lower heel. -Left upper heel. Review of resident 9's 5/22/19 care plan revealed: There were no focus, goals, or interventions related to the brace/splint she had been admitted with on her right hand. She was identified to be at risk for skin breakdown on 1/15/19 and the interventions included: -Pressure reducing cushion to wheelchair (w/c) initiated on 1/18/19. -Weekly skin observations by a nurse initiated on 1/18/19. -Heel protector boots on both feet while in bed initiated on 5/21/19. -Pressure redistributing mattress on her bed initiated on 1/18/19. -Staff to monitor for potential skin breakdown imitated on 1/18/19. -Staff to lay her down between meals and reposition at least every two hours imitated on 5/6/19. Multiple observations of resident 9 on 5/21/19 from 7:51 a.m through 2:04 p.m. revealed: Resident wearing no heel boots while in bed. Resident wearing a heel boot only on her right foot in wheelchair and in bed. Observation and interview on 5/21/19 at 04:23 p.m. with licensed practical nurse (LPN) J of resident 9 revealed: She had identified a circle about the size of a quarter on the inside of her left heel that was hard and unblanchable. She was unable to locate two heel boots in the resident's room when finished with her assessment. She had verified the one heel boot on the right foot had been put on incorrectly. Multiple observations on 5/22/19 and 5/23/19 from 8:15 am through 6:00 p.m. resident 9 had been wearing two heel boots correctly. Interview on 5/23/19 at 8:16 a.m. with the medical director regarding her role in wound management revealed: She assisted with identifying people at risk, their risk factors, and implementing preventative measures. Sometimes it was hard to determine if a wound was preventable. -Sometimes they knew they should have been more on top of the risk factors. How to manage wounds after they had developed. Utilized the wound care clinic, physical therapy, occupational therapy, speech therapy and dietary. Resident 9's hand wounds were related to the wrist splint. -Nursing was to notify the physician when the splint had been moved or was ill fitting. -She had never observed her messing with the sling. Interview on 5/23/19 at 9:08 AM with the director of nursing (DON) and administrator regarding resident 9's pressure ulcers revealed: -There was no documentation for evaluating her for a low air loss mattress. -All mattress's in the facility were pressure redistributing and were evaluated by the manufacture annually. -The expectation would be for her to have both heel boots on at all times. 2. Review of resident 45's medical record revealed: She was admitted on [DATE]. Her BIMS score was zero indicating her cognition was severely impaired. She required the extensive assistance of one staff member for bed mobility. She required the extensive assistance of two staff members for transferring. Review of resident 45's weekly Pressure wound assessments from 4/21/19 through 5/21/19 revealed on: 4/21/19 four stage two pressure ulcers were identified. -Right buttock. -Left buttock. -Lower coccyx. -Upper coccyx. 4/23/19 right buttock pressure ulcer was healed. 4/30/19 all pressure ulcers were healed. 5/7/19 two pressure ulcers were identified. -Stage one on left outer ankle. -Stage two on right inner ankle. 5/14/19 she was seen by wound care and the pressure ulcers on her ankles were verified. Observation and interview on 5/21/19 at 1:45 p.m. of resident 45's pressure ulcers revealed: Certified nursing assistant (CNA) O pointed out a spot on her left outer ankle that was painted with [MEDICATION NAME]. She verified the resident had a pressure injury on her right inner ankle that was covered with a bandage. She placed the resident's heel boots on after she was laid down in bed. Interview on 5/21/19 at 2:25 p.m. with resident 45's representative revealed: She did not know about the pressure ulcers on her heels. She did have a pressure ulcer on her buttock at one time. -She had been told they had healed the one on her buttock. Review of resident 45's 5/22/19 care plan revealed: She was identified to be at risk of skin breakdown on 8/3/15. On 8/3/15 she required frequent reminders to shift her weight when she was sitting in her w/c. -Revised on 4/29/19. On 5/17/19 she needed to have a pillow between her knees and ankles to to prevent her skin from rubbing on itself. -She also needed heel boots to off load her feet. On 4/24/19 a gel cushion was implemented for her w/c. On 10/24/16 she needed assistance to change positions every two hours. Interview on 5/22/19 at 6:16 p.m. with the DON and administrator revealed: Roho cushion (pressure relieving) was put into place on 4/23/19, prior to gel cushion, initiated on 4/24/19. -Verified interventions were put into place after she had developed four pressure ulcers on her buttock. She would need to be assessed to know if she could off load herself. -She had needed less assistance when her care plan was developed. The administrator personally educated staff to put pillows between her knees and ankles prior to the wound development. -She did that education on the day she was assessed to require a total body lift. (Date unknown) 3. Review of resident 73's medical record revealed: She was admitted on [DATE]. Her BIMS score was thirteen indicating her cognition was intact. She was totally dependent on two or more staff members for: -Transfers. -Bed mobility. Her weekly pressure wound assessments from 5/2/19-5/21/19 revealed on: 5/2/19 a stage two pressure ulcer was identified on her left buttock. -Will try off loading from buttocks when in bed. 5/14/19 the area was healed. 5/21/19 stage two pressure ulcer was identified on her coccyx. Interview on 5/21/19 at 9:46 a.m. with Resident 73 revealed she had developed a sore on her buttock since her admission. Observation on 5/22/19 at 10:40 a.m. of resident 73 revealed she was her in w/c in her room with the Hoyer sling under her. Observation and interview on 5/22/19 at 2:07 PM with resident 73 revealed: She was still sitting in her w/c. She denied that she had been laid down, since getting up for therapy, after breakfast. She was tearful and stated I am still in my damn chair when asked about repositioning. Observation and Interview on 5/22/19 at 2:10 p.m. with resident 73 revealed: Two staff taking a total lift into her her room. She was transferred into her recliner and staff left. She indicated that at first her buttock hurt because of her pressure injuries. When they began treatment for [REDACTED]. She tried to move around in her chair when her bottom would hurt. She would lay in bed for long periods of time without assistance to reposition prior to her pressure injuries. She started to get assistance with repositioning after her pressure injury developed. Interview on 5/22/19 at 4:51 p.m. with the DON and administrator regarding resident 73 revealed: Everyone who lives in the facility is to be repositioned every two hours unless specified otherwise. It is standard for the resident to be repositioned every 2 hours even if she was in a w/c. Review of resident 73's 5/22/19 care plan revealed on 1/29/19: She was identified to be at risk for skin breakdown. She had a pressure redistributing pad on her chair and mattress on her bed. She was to have a skin assessment by a nurse weekly and staff were to monitor for potential skin breakdown. There was no indication to assist resident with repositioning. 4. Observation on 5/21/19 at 1:40 p.m. of LPN J while she completed wound care for resident 56 revealed: The resident had a pressure relieving mattress on her bed and in her wheelchair. There had been a white terry cloth hand towel underneath the resident's buttocks. -LPN J: --Asked the resident what it was for and she did not know. --Left that wrinkled, terry cloth towel was left in place. LPN J assisted the resident to position on her left side. She: -Removed the [MEDICATION NAME] gentle and looked at her buttocks. -Stated: --There was a dark red area on her buttocks. --It was slightly elevated and irritated. --It extended upward from the resident's tailbone approximately four inches. -Completed the resident's treatment and had her onto her back. -Provided no care or additional interventions for the newly identified reddened skin area on the resident's tailbone. Review of resident 56's care plan with a print date of 5/22/19 revealed: A focus area for a pressure wound. The newly identified skin area of 5/21/19 had not been identified on the current care plan. There had been no nonpharmacological interventions in place for the resident to assist her in repositioning and off loading her tailbone area. There had been one intervention that stated the resident refused pillows and staff assistance. -Observations on 5/21/19 from 9:00 a.m. through 12:00 p.m. and again from 1:15 p.m. through 5:00 p.m. revealed no staff had been observed asking her if she wanted help to reposition. -Observation on 5/22/19 from 9:30 a.m. through 12:30 a.m. and again from 2:00 p.m. through 4:30 p.m. revealed no staff had been observed asking her if she wanted help to reposition. Interview on 5/23/19 at 10:45 a.m. with the DON regarding resident 56's revealed she agreed: The wrinkled terry cloth towel should not have been left under her. The reddened area on her buttocks had required follow-up by LPN [NAME] 5. Observation on 5/21/19 at 1:20 p.m. of LPN J while she completed a dressing change to resident 62's right heel revealed: The resident was sitting in her recliner. No pressure relieving device on or under her right heel. She removed the dressing from the resident's right heel. Used a compact mirror to view the wound on her heel. She stated Oh, the blister has opened. Did not ask the resident or assist her to off load her right heel after the dressing change had been completed. Review of the weekly wound and pressure assessments for resident 62 revealed LPN J documented: 4/2/19 there had been a blister to the resident's right heel. 4/9/19 the fluid filled blister had been unchanged. Area to right heel the blister had now popped. Area has separated at the upper edge flap intact. had moderate amount of drainage noted. will cover with [MEDICATION NAME] no [MEDICATION NAME] to area if more drainage may start to use calcium alginate. 4/23/19 a note by LPN J stated Resident blister broke open last week. Is dry no drainage noted. 5/21/19 LPN J recorded This presented as a fluid filled blister when admitted from hospital. Has been dry no fluid. Top of wound came off today with wound care. Area is bloody with serous sangious () drainage to area. Lower part of wound still has slough/eschar to wound bed. Are covering with foam border dressing over area. Review of resident 62's current care plan printed on 5/22/19 revealed: A focus area for skin breakdown. The interventions for the above areas had been I am refusing foam boots, staff will continue to offer these. offer pillows to offload heels when in bed. Observations on 5/21/19 from 9:00 a.m. through 12:00 p.m. and again from 1:15 p.m. through 5:00 p.m. revealed no staff had been observed asking her if she wanted help to reposition. Observation on 5/22/19 from 9:30 a.m. through 12:30 a.m. and again from 2:00 p.m. through 4:30 p.m. revealed no staff had been observed asking her if she wanted help to reposition. there had been no area of intervention that had been nonpharmacological on resident 62's care plan. Interview on 5/22/19 at 10:30 a.m. with resident 62 revealed no staff ask her if she would like to off load her right heel while she is sitting in her recliner. She stated I don't always want to but they don't ask. I should have asked them. 6. Review of resident 32's 9/19/18 admission assessment Minimum Data Set (MDS) revealed: Her admitted was 9/12/18. Her 9/12/18 Braden scale assessment for predicting pressure sores was 13 indicating she was at moderate risk. There was no Brief Interview for Mental Status (BIMS) assessment score due to significant cognitive impairment. She required extensive assistance with a physical assist of one for: -Bed mobility. -Transfers. -Dressing. -Eating. -Toilet use. -Personal hygiene. She was frequently incontinent of urine and bowel movements. She was at risk for pressure ulcers (PU). She had no unhealed PU's. She had interventions in place for a: -Pressure reducing device for her chair. -Pressure reducing device for her bed. There was no hospice or respite care. Review of resident 32's 12/18/18 quarterly MDS assessment revealed: There was no Brief Interview for Mental Status (BIMS) assessment score due to significant cognitive impairment. She was rarely understood. She had a mechanically altered diet. She required extensive assistance with a physical assist of two for: -Bed mobility. -Transfers. She required extensive assistance with a physical assist of one for: -Dressing. -Eating. -Toilet use. -Personal hygiene. She was always incontinent of urine. She was frequently incontinent of bowel movements. She was on a mechanically altered diet. She was at risk of PUs. She had one unstageable PU due to non-removable dressing/device. She had two unstageable PU with suspected deep tissue injury's. She had interventions in place for a: -Pressure reducing device for her chair. -Pressure reducing device for her bed. -Nutrition or hydration intervention. -PU care. There was no: -Turning or repositioning schedule. -No hospice or respite care. Review of resident 32's 3/18/19 quarterly MDS assessment revealed: There was no Brief Interview for Mental Status (BIMS) assessment score due to significant cognitive impairment. She was rarely understood. She had a mechanically altered diet. She required extensive assistance with a physical assist of two for: -Bed mobility. -Transfers. -Dressing. -Eating. -Toilet use. -Personal hygiene. She was frequently incontinent of urine and bowel movements. She had no swallowing disorder. She was on a mechanically altered diet. She was at risk of PUs. She had one stage two PU. She had one stage four PU. She had interventions in place for a: -Pressure reducing device for her chair. -Pressure reducing device for her bed. -Turning and repositioning schedule. -Nutrition or hydration intervention. -PU care. There was no hospice or respite care. Interview on 5/23/19 at 9:08 a.m. concerning resident 32 with the director of nursing and administrator revealed: The administrator meets with staff providing care. She made sure interventions were in place and being provided to residents. She stated resident 32 was on a repositioning schedule. -She expected everyone to reposition themselves if capable. If unable to reposition themselves: -They would have contacted physical therapy (PT) and occupational therapy (OT). -Assessed for grab bars. -Put nutritional interventions into place. She agreed there were no repositioning or foam boot interventions. -Stated even though there was no documentation, those interventions were done for everyone. She agreed those interventions were not documented until after she developed PUs. Interview on 5/23/19 09:48 a.m. with the Medical Director, her nurse, and the administrator concerning resident 32 revealed: She had dysphagia. She had spoken with the daughter and established goals of care. -She was not to go to the hospital because of advancing: -Dementia. -Dysphagia. She was to have no feeding tube. She was not eating. PT and OT were involved for: -A wheelchair cushion. -The safest way to transfer her. Dietary was involved. There was a swallowing evaluation performed. The medical director stated with all the above in place she still developed a PU. The medical director believed the PU was unavoidable. She did agree there were other interventions that could have been in place proactively related to: -Foam boots. -Turning and repositioning schedule. -Nutrition and hydration interventions. She agreed she did not have PUs when she was admitted . She agreed she was at moderate risk of developing PUs when admitted . The MD stated the resident's daughter agreed to sending her to wound care. The facility did what they could to keep her comfortable and get her better. If you would have asked me I would have thought that she would be in hospice. Any PU on paper is unpreventable but you have to look at the person. She took a dip and now she is functioning better. Review of resident 32's weekly wound care documentation for a right heel wound revealed: Date of onset was 10/10/18. It was facility acquired (FA). A suspected deep tissue injury from 11/6/18 through 12/11/18. A stage one PU on 12/11/18. A stage one PU on 12/18/18. Not staged on 12/24/18. A stage three PU on 12/28/18 and 2/5/19. Review of resident 32's weekly wound care documentation for a left heel wound revealed: Date of onset was 12/11/18. It was F[NAME] A PU on 11/6/18 was not staged. A stage three PU from 12/18/18 through 1/8/19. A suspected deep tissue injury on 1/15/19. A stage three PU from 1/22/19 through 1/29/19. A stage three PU from 2/12/19 through 2/19/19. A stage four PU from 2/26/19 through 3/5/19. A stage three PU on 3/5/19. A stage two PU from 3/12/19 through 4/02/19. Review of resident 32's weekly wound care documentation for a right buttock wound revealed: Date of onset was 11/13/18. It was F[NAME] A blister on 11/13/18. A stage one PU on 11/20/18. A suspected deep tissue injury from 11/27/18 through 12/4/18. An unstageable PU on 12/11/18. A stage four PU from 12/24/18 through 1/29/19. A stage four PU from 2/12/19 through 2/19/19. A stage three PU on 2/26/19. A stage four PU on 3/5/19 through 4/30/19. Progress note on 5/22/19 indicates weekly wound care has been completed. Review of resident 32's weekly wound care documentation for a left buttock wound revealed: Date of onset was 11/3/18. It was F[NAME] Not stageable on 11/13/18. A stage two PU on 11/20/18. A stage four PU on 12/18/18, 12/28/18, and 2/5/19. Review of resident 32's weekly wound care documentation for a sacrum wound revealed:It was F[NAME] A stage two PU on 11/20/18. Review of resident 32's weekly wound care documentation for a coccyx wound revealed: A stage two on 11/27/18. It was F[NAME] Healed on 12/4/18. *There was no other documentation given to this surveyor concerning this residents wound care during the survey.	2020-09-01
103	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	689	D	1	0	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, and policy review, the facility failed to ensure one of one sampled residents (60) who was totally dependant was transferred safely. Findings include: Review of resident 60's 4/25/19 Minimum Data Set (MDS) assessment revealed: She was admitted on [DATE]. Her Brief Interview for Mental Status (BIMS) score was zero indicating her cognition was severely impaired. She required the extensive assistance of two staff for: -Bed mobility. -Dressing. -Toilet use. She was totally dependent on two or more staff for transfers. Interview of 5/21/19 at 8:51 a.m. with resident 60's representative revealed: She felt the lift used to transfer her mother caused pain. There were two men who worked in the evening who would help get her mother to bed. -She could not remember their names. She had asked them to pick her mother up and move her from the chair to the bed and vice versa. She had witnessed them moving her in this manner, without the lift and believed that it was easier on her mother. Interview on 5/22/19 at 3:19 p.m. with certified nursing assistant (CNA) H regarding resident 60 revealed she: Required a full lift transfer. Denied seeing signs or symptoms of pain for the resident during transfer. Denied seeing anyone transfer her without a lift, stating it would be unsafe. Interview on 5/22/19 3:22 p.m. wit CNA I regarding resident 60 revealed he had: Met resident 60's representative. Never seen or heard of anyone transferring her without a lift. Would not transfer the resident without a lift because it would jeopardize his job. Interview of 5/22/19 at 2:41p.m. with the administrator and the director of nursing (DON) regarding resident 60 revealed: They would not be surprised if the family asked for the resident to be transferred without the lift. They would be surprised if the staff would transfer her without the lift. They had not heard of this happening. They did not transfer people without the total lift if they had been assessed to need the lift. Review of provider's Qtr3, (YEAR) Safe Lifting and Movement of Residents policy revealed: The provider will use appropriate techniques and devices to lift and move residents to protect their safety and well-being. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.	2020-09-01
104	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	697	D	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow professional standards for pain management for one of one sampled resident (56) who had high pain levels. Findings include: 1. Observation and interview on 5/21/19 at 3:43 p.m. of licensed practical nurse (LPN) J while she changed the surgical site dressing for resident 56 revealed: The resident was moaning and stating aloud she was having pain at her surgical site when LPN J was removing the dressing. LPN J: -Stated Bear with me and continued to remove the dressing. -Thought she had administered pain medication about one hour ago but it must not have been enough. -Did not attempt to loosen the adhering parts of the dressing before pulling it from the resident's skin. -Did not attempt any nonpharmacological methods of pain management. Review of resident 56's medical record revealed she had: Been admitted on [DATE]. A [DIAGNOSES REDACTED]. A recent surgical procedure of (type of surgery). An order to Cleanse wound with wound cleanser, dress with border gauze and apply stockinet to(name of area) every day shift for wound care. As needed pain medications of: -[MEDICATION NAME] Tablet 5 MG ([MEDICATION NAME] HCL) Give 1 tablet by mouth every 4 hours as needed for PAIN SCALE 8-10 OR 4-7 DO NOT EXCEED 60 MG/DAY Hole if RR rate --LPN J had administered the above medication to the resident at 2:20 p.m. -[MEDICATION NAME] Tablet 5 MG ([MEDICATION NAME] HCL) Give 2 tablet by mouth every 4 hours as needed for PAIN SCALE 8-10 OR 4-7 DO NOT EXCEED 60 MG/DAY Hold if RR rate --LPN J had not administered two tablets of the pain medication pretreatment for [REDACTED]. --She did not stop the treatment when the resident was in pain to provide her the additional pain medication. LPN J had administered the lowest dose of [MEDICATION NAME] to the resident for premedication prior to a painful treatment. LPN J stated the above was her usual practice for resident 56's wound care. Review of resident 56's care plan printed on 5/22/19 revealed no mention of surgical pain management. Interview on 5/23/19 at with the director of nursing regarding resident 56's pain management revealed LPN J should have: Attempted nonpharmacological methods of pain management during the treatment. Provided additional pain medication for resident 56 when she exhibited pain. Review of the providers Qtr 3, (YEAR) Wound Care policy revealed: Review the resident's care plan to assess for any special needs of the resident.*For example, the resident may have PRN (as needed) order for pain medication to be administered prior to would (wound) care.	2020-09-01
105	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	745	D	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the provider failed to ensure: 1. One of one sampled residents had a complete and documented discharge plan. 2. One of one sampled residents had support in the transition from rehabilitation to long term care. Findings include: 1. Review of resident 9's 5/3/19 Minimum Data Set (MDS) assessment revealed: Her admitted was 4/22/19. Her Brief Interview for Mental Status (BIMS) score was a three indicating she was severely cognitively impaired. Her family participated in the assessment and no discharge expectation was identified. Interview on 5/21/19 at 2:20 p.m. with resident 9's representative revealed: He lived an hour away from the facility and would like for her to be closer. It was hard for him and other family to visit due to the distance. He did not feel he was getting much help from the provider to find a closer placement for her. Interview on 5/23/19 at 10:20 a.m. with the social services designee (SSD) regarding resident 9's discharge plan revealed: She was aware the resident's representative wanted her to be moved to a facility closer to her hometown. She indicated the resident's representative had toured facilities closer to family. -In those tours he had identified facilities that would be a good fit for her. -She had made referrals to those facilities for the resident. She indicated monthly she followed up with the facilities that she had referred the resident to. She agreed she did not have documentation of the referrals. She agreed she did not have documentation of the follow up calls she had made regarding the referrals. She agreed she should have documented the resident's discharge plans. Review of resident 9's 5/21/19 care plan revealed: She required long term care placement. She would like to be transferred to a facility in her hometown to be closer to family. She was on several waiting lists at facilities in her hometown. There was no identifications of which facilities she had been referred to. Record review for resident 9 revealed: There was no documentation of the referrals that had been made to other facilities. There was no documentation of the follow up for the referrals made. 2. Review of resident 23's 3/1/19 (MDS) assessment revealed: She was admitted to the facility on [DATE]. Her (BIMS) score was twelve indicating her cognition was moderately impaired. She had a [DIAGNOSES REDACTED]. She had received an antidepressant seven of seven days in the assessment look back period. She has received no psychological therapy. Interview on 5/21/19 at 11:36 a.m. with resident 23 revealed: She indicated she was sad often. She had a history of [REDACTED]. Her affect was very flat when talking with her. Interview on 5/23/19 at 10:41 a.m. with the SSD regarding resident 23 revealed: She was aware of resident 23's flat affect. She had been informed by the family that historically she had a flat affect. She agreed that with moving from assisted living to rehabilitation to long term care was a great loss for the resident. She stated I should probably offer Deer Oaks, which is a therapy service. Review of resident 23's 3/15/19 care plan revealed there were no goals or interventions related to her mood or behavior.	2020-09-01
106	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	868	E	0	1	LF7K11	Based on interview, record review, observation, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to residents' care within the facility. Findings include: 1. Interview on 5/23/19 at 11:45 a.m. with the administrator regarding the QAPI program revealed: The committee met monthly. The medical director attended most months She had identified a problem with facility acquired pressure ulcers. -Started an Action Plan but had not fully implemented it. -The action plan had no implementation date or measurable goals. They had not identified all the areas of concern identified during this recertification survey. They had no performance improvement plans (PIP) in place right now. Review of the provider's undated Quality Assurance and Performance Improvement (QAPI) policy revealed: Purpose Statement: Our organizations written QAPI plan provides for our overall quality improvement program. Quality assurance performance improvement principles will drive the decision making within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. Focus areas will include all systems that affect resident and family satisfaction, quality or care and services provided, and all areas that affect the quality of life for persons living and working in our organization. The QAPI committee will review area our organization believes it needs to monitor on a regular basis to assure systems are monitored and sustained to achieve the quality for our organization. Our organization will utilize evidence based practices and data to define our goals and guide our decisions. Our organization will utilize evidence-based practices and data to define our goals and guide our decisions. Comparison data from our corporation, state and national sources will be used to guide decisions. Refer to F550, F656, F684, F686, F689, F697, F745, and F880.	2020-09-01
107	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	880	E	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed the ensure infection control practices were followed for: Cleaning of therapy equipment between resident use by one of one certified occupational therapy assistant (COTA) W. Cleaning and sanitizing of equipment between resident use and disposal of single use items by licensed practical nurse (LPN) (J) following wound care for residents 32 and 56. Use of the Micro Kill Bleach wipes had been used effectively for one of one resident (128) by one certified nurse aide (CNA) (V) observed. Catheter bag placement for one of one observed resident (125). Personal protective equipment (PPE) had been used correctly by CNA (T) and two unidentified CNAs. Hand hygiene had been completed by CNAs H, K, L, and M, and by registered nurse (RN) (L) and (F). Cook Y had completed hand hygiene at appropriate times while preparing food during one of two meal preparation observations. Findings include: 1. Observation on 5/21/19 at 9:28 a.m. of COTA W while he worked with two random residents revealed: He used clothes pin clips with the first resident. With the second resident he used cones and a ball and stick. The ball and stick and clips were put directly in the supply cupboard after use without cleaning or sanitizing. Observation and interview on 5/23/19 at 9:33 AM with the COTA W while he worked with resident 125 revealed: He used pegs and a peg board with the resident. -He put the equipment directly back into the supply cupboard without cleaning or sanitizing them. Stated he usually wiped off the equipment after use but forgot to sometimes. Agreed the equipment should have been cleaned after use with each individual resident. Interview on 5/23/19 at 10:07 AM with the director of physical therapy revealed he expected the resident use equipment to have been sanitized after use and before putting it away. Interview on 5/23/19 at 3:07 p.m. with the director of nurses revealed she expected RN F to have washed her hands when changing gloves from soiled to clean. She agreed the supplies used for the resident's wound care should not have been laid on the unclean beside table or bed sheet. 2. Observation on 5/21/19 from 1:20 p.m. through 1:40 revealed she: Used two paper single-use measuring tape strips to measure resident 56's wounds. Used two paper single-use measuring strips to measure resident 62's wounds. Used a compact packet mirror to view and measure resident 62's heel wound. Used her pocket sanitizer and rubbed it on the outside of the compact mirror. Put all the paper measuring tapes she had used on the nurse's desk. -That desk had papers, cups, pens, and pencils laying on it. Interview on 5/23/19 at 3:07 p.m. revealed she agreed: The paper measuring tapes should have been disposed of, not placed at the nurse's station. Hand sanitizer had not been the correct product to use on the compact mirror. Review of the provider's revised (MONTH) 2014 Cleaning and disinfection of Resident-Care Items and Equipment revealed: Single use items were to have been disposed of. Reusable resident care equipment was to have been cleaned and disinfected before reuse by another resident. Intermediate or low-level disinfectants for non-critical items included: -Ethyl or [MEDICATION NAME] alcohol. -Sodium hypochlorite (5.25-6.15% diluted 1:500 or per manufacturer's instructions). 3. Observation on 5/21/19 of CNA V while she cleaned bowel movement and urine from the floor revealed she: Wiped it up with dry cloth. Then wiped the same area with a cloth wet with water. Wiped the same area with MIcro Kill Bleach wipes. Immediately dried the area she had wiped with the wipes Stated I dry it right away. Had been unsure if there had been a wet time for effectiveness of the Micro Kill Bleach wipes. Review of the Micro Kill Bleach wipes package revealed the surface contact wet time was thirty seconds. Interview on 5/23/19 at 3:30 p.m. with the DON revealed her expectation was to follow the manufacturer's direction on the package. 4. Observation on 5/21/19 at 3:23 p.m. of resident 125 while sitting in a chair in the therapy room revealed revealed her indwelling catheter straight drainage bag was laying directly on the floor underneath her chair. Interview with PTA A and CNA U at that time revealed that was usual practice in the therapy room. Interview on 5/23/19 at 3:15 p.m. with the DON revealed she agreed the urinary drainage bag should not have been on the floor. 5. Observation on 5/20/19 at 5:55 p.m. of resident 53's room. CNA's were entering the room wearing gowns and gloves. There had been no sign on the door to alert others of contact precautions. Interview on 5/21/19 at 2:21 p.m. with DON regarding resident 53 revealed: Staff were to follow contact precautions by gowning and gloving prior to entering his room. After care staff should have taken off gown and gloves and placed them into the garbage receptacle before exiting the room. Staff should have been aware of contact precautions that were in place for him due to personal protective equipment (PPE) being outside of the room. The staff should have known to gown and glove when they saw the PPE outside the doorway. The DON stated he had no visitors that needed to be informed of the precautions in place. Volunteers would have known about the precautions in place without the need for a sign. Observation on 5/21/19 of restorative aide, CNA T at 8:46 a.m. revealed she had: Walked next to resident 53 returning from a therapy session. Assisted him into his room and into his recliner without putting on gown and gloves. Not followed contact precautions prior to entering his room or performed hand hygiene prior to leaving. Interview on 5/22/19 at 8:49 a.m. with restorative aide T revealed: She was aware she had not gowned or gloved prior to entering his room. She had not followed contact precautions that had been in place. She stated they usually had gowned and gloved prior to entering his room. Interview on 5/23/19 with the DON at 10:08 a.m. revealed: Contact precautions had been discontinued on 3/15/19. Acknowledged staff had continued to follow precautions even though the order was discontinued. A new order had been obtained on 5/21/19 for contact precautions to begin. Review of resident 53's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED]. His history included an infection extended spectrum beta lactamase (ESBL) since 11/2/18. Contact precautions were initiated on 11/2/18. On 3/11/19 a pressure ulcer was identified on his left calf. Review of resident 53's 3/15/19 care plan revealed: Contact precautions had been discontinued on 3/15/19. -Staff had continued to follow contact precaution practices. A physician order [REDACTED]. Review of the provider's dated Quarter 3, (YEAR) Isolation Categories of Transmission-Based Precautions policy and procedure revealed: Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Implement contact precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 6. Observation on 5/20/19 at 3:41 p.m. of LPN J entering resident 66's room revealed: The resident was on contact precautions. Without performing hand hygiene LPN J put on a gown and gloves. She placed the catheter cover over the catheter bag and hung it on the bed. She removed her gown and gloves in the room. She placed those items into an approximately two-and a-half foot high contamination box. She used hand foam and left the room. Observation on 5/20/19 at 3:48 p.m. of LPN J entering resident 66's room revealed: The resident was on contact precautions. Without performing hand hygiene, LPN J put on a gown and gloves. She checked the catheter strap -It was secure. She removed her gown and gloves in the room. She placed those items into an approximately two-and a-half foot high contamination box. She used hand foam and left the room. Interview on 5/22/19 at 3:53 p.m. with LPN J concerning the above observation revealed: She agreed she had not performed hand hygiene either time before putting on her gloves and entering the room. She stated there were no foam sanitizer's in the hallway to use. She should have used the sink in the activities room to wash her hands prior to gloving. -The activity room was approximately ten feet away. She stated every room has foam sanitizer. -She was unable to use the foam sanitizer because she needed to gown and glove up before entering 7. Observation and interview on 5/20/19 at 4:19 p.m. with CNA K in resident 72's room revealed: He went into her room. Without hand hygiene he: -Placed resident into the EZ stand. -Moved her into her bathroom. Without hand hygiene he: -Put on gloves. -Pulled down her pants. -Removed her brief and placed it in the trash can. -Removed his gloves. Without hand hygiene he: -Put new gloves on. -Lowered resident onto the toilet. -Put a new brief around her legs. -Moved her wheelchair. -Picked up the room. -Removed his gloves. Used hand sanitizer and put on gloves. Raised the resident from the toilet with the EZ stand. Wiped her. With the same gloved hands he: -Pulled up her brief. -Pulled up her pants. He removed his gloves. Without hand hygiene he: -Lowered the resident into her wheelchair using the EZ stand. When questioned about his hand hygiene CNA K stated: -I should have performed hand hygiene before going into her room. -I should have performed hand hygiene after removing my gloves. 8. Observation and interview on 5/20/19 at 4:37 p.m. of CNA K in resident 24's room revealed: He helped the resident into her wheelchair and into her bathroom. -He helped her stand. Without putting on gloves he: -Pulled her pants down. -Pulled her brief down. Left the resident on the toilet and without washing his hands: -Straightens out her bed. -Cleans up around her room. Helped resident out of the bathroom. Used hand sanitizer and left the room. When questioned about his hand hygiene CNA K stated: -He did not use good hand hygiene. -He gets busy. -Had a lot of call lights and residents to get to. -Should have used more hand hygiene.9. Observation on 05/21/19 at 7:41 a.m. of resident 52 during a brief change revealed: RN L was called into the room. -She had been asked to view the residents skin. Without washing or sanitizing her hands she put on gloves. She looked at the residents skin concern. She removed her gloves. She used the foam sanitizer and left the room.Surveyor . Observation on 5/23/19 12:49 PM of RN F while she completed wound care for resident 73 revealed she: Changed her gloves from soiled to clean five times. She did not complete hand hygiene any of those five times. Interview on 5/23/19 at 3:07 p.m. with the director of nurses revealed she expected RN F to have washed her hands when changing gloves from soiled to clean. She agreed the supplies used for the resident's wound care should not have been laid on the unclean beside table or bed sheet.10. Observation on 5/21/19 at 4:08 p.m. of CNA K delivering fresh ice water in bubble cups to residents revealed: Without wash his hands he put on a gown and gloves. He took a new bubble cup into the room. He removed his gown and gloves in the room. He placed those items into an approximately two-and a-half foot high contamination box. He used foam sanitizer and left the room. -He had the used bubble cup from the room in his hand. He placed that bubble cup on the bottom shelf of the metal cart. -There were other used cups on that shelf. The metal cart held: -Bubble cups filled with fresh water and ice. -A square container of snacks. -Ice and soda's. He took the cart into the bistro serving area. -He delivered two of those soda's to resident's in the open court area. -He placed the unused bubble cups of water and soda's into the fridge. -He placed the unused snacks into the cabinet. -He left all the used bubble cups on the cart. He left the bistro area and used a sink outside of that area to wash his hands. 11. Observation and interview on 5/22/19 at 1:18 p.m. of CNA M, in resident 52's room revealed: CNA M walked into the room. She noticed the wet area on the floor and to the resident's sweat pants. She stated she had offered to lay her down at approximately 10:00 a.m. so she could change her brief. -The resident had refused. She used her Walkie Talkie to ask for assistance to the room. She left and returned with a mop and bucket. She mopped up the wet area on the floor to the rear of the w/c. She picked the bubble cup up from the floor. -She placed it onto the residents over-the-bed table. -It was next to her lunch tray. -It was put next to her other two bubble cups. -There was now a total of three bubble cups next to her lunch. --Two filled with an orange liquid. --One with a brown liquid. She went into the bathroom and without washing her hands she put on gloves. At 1:38 p.m. CNA M removed her gloves. -She did not perform any hand hygiene. -She left the room. 12. Interview on 5/23/19 at 12:40 p.m. with the administrator concerning the above observations in findings 6, 7, 8, 9, 10, and 11 revealed:The employees had their own hand sanitizer.They could use their hand sanitizer or the foam sanitizer in the rooms.They needed to perform hand hygiene:-Going into or out of a room.-Before putting on gloves.-After removing gloves. 13. Observation and interview on 5/21/19 from 11:15 a.m. to 11:43 a.m. of cook KY revealed: She took the temperature of the chicken to ensure that it was hot enough to serve. She cut the chicken into smaller pieces to grind. She had gone into the refrigerator to get cheese to add to the chicken. She had opened the cupboard to get a plastic spoon, which she used to check consistency of the chicken. She got a metal pan, sprayed it with cooking spray and transferred the ground chicken into it. She added more chicken to the grinder and began the puree process. She was taking the lid on and off the grinder to check the consistency of the chicken. She went to get another metal pan, sprayed it with cooking spray and transferred the pureed food into it. She put on oven mitts and picked up a pan of boiling vegetables. She poured the vegetables into the blender and began to puree them. She was adding slices of bread into the blender of vegetables with her bare hands. She went to get another metal pan, sprayed it with cooking spray and then transferred the vegetables into it. She covered the chicken and vegetables with foil and placed the pans into the oven after putting on oven mitts. She got the rice that was cooking on the stove and added it to another blender to be pureed. She went to the dining room three times to get hot water from the coffee dispense to add to the rice. She got into the cupboard again to get a plastic spoon to check the consistency of the rice. She went to get another metal pan, sprayed it with cooking spray and added the rice to it. She covered it with foil and added it to the oven. There was no observation of hand hygiene during this process. Interview on 5/23/19 at 10:02 a.m. with the certified dietary manager and the dietician verified that cook Y had missed some opportunities for hand hygiene in her food preparation on 5/21/19. Review of the provider last revised (MONTH) (YEAR) Handwashing/Hand Hygiene policy revealed: All personnel were to have followed the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. An alcohol-based hand rub or soap and water was to have been used: -Before and after direct contact with residents. -After removing gloves.	2020-09-01
108	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	550	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, call light audit review, and admission packet review, the provider failed to ensure dignity was maintained for one of one sampled resident (44) who had an incontinence issue. Findings include: 1. Observation and interview on 2/25/20 at 8:41 a.m. and again on 2/26/20 at 2:07 p.m. with resident 44 revealed: She had been resting in her recliner with her feet up with the call light next to her on her bedside table. Call lights had been answered slowly at times. She waited anywhere from thirty minutes to an hour for staff assistance. Due to her [DIAGNOSES REDACTED]. She had not usually been incontinent of urine but was concerned about the BM accidents she had. She chose to eat evening meals in her room at times to avoid BM accidents and long waits for assistance from staff to return to her room after she ate in the dining area. -It was difficult for her to sit for long periods of time due to back problems, and she also felt more tired in the evenings. She could get to the restroom independently using her walker. There was episodes when she could not make it in time and had BM all over that needed to be cleaned up. -When she pressed her call light for assistance, the wait after a BM accident was long. She thought the facility was short staffed at times which caused slow call light response times. -Staff had apologized to her for the long waits. She thought her last BM accident had been ten to twelve days ago. BM accidents usually happened about twice a month. That had happened mostly in the morning and sometimes in the afternoon. She stated she hated it, and it embarrassed her. Review of resident 44's medical record revealed: She was admitted to the facility on [DATE]. Her 12/24/19 Brief Interview for Mental Status (BI[CONDITION]) score was fifteen indicating she had no cognitive deficit. She had multiple [DIAGNOSES REDACTED]. She had frequently been incontinent of bowel. She walked independently in her room with the use of a walker and also used a wheelchair (w/c) when out of the room. She required assistance of one staff person to move off the toilet and for perineal care. Her undated, 11/16/18 revised care plan reflected the need for assistance with her activities of daily living. Interview on 2/26/20 at 2:34 p.m. with certified nursing assistant (CNA) R regarding resident 44 revealed: She was familiar with the resident, knew she had BM accidents, but had not assisted her after an accident took place. Agreed sometimes it took the CNAs a long time to answer the call lights. The facility completed audits on the call lights to see how long the waits really were, and the assistant director of nursing J had that information. Interview on 2/27/20 at 9:20 a.m. and at 10:08 a.m. with CNA Q regarding resident 44 revealed: She was familiar with her and had assisted her regularly. The staff tried to get in there as soon as possible if her light went off, because if she had a BM accident it would be all over and take time to clean up. She was a CNA lead trainer for newly hired CNAs. -The facility expectation would be for staff to get to the residents within fifteen minutes or as soon as possible. -That was when the call light marquis would start to flash if it had not been answered. -That alerted the staff those flashing room numbers would be a priority. As a mentor she trained the CNAs to try to get to the residents within five minutes if possible. Weekends were a real problem for staffing. They were fully staffed maybe twice a week. Interview on 2/27/20 at 11:41 a.m. with director of nursing A regarding resident 44 revealed: Her expectation was the staff would answer the call lights as soon as possible or prior to thirty minutes. Audit reports were completed and reviewed each morning by her and assistant director of nursing J. If a long call light had been identified she would contact a CNA to follow-up. She admitted there had been long call light wait times, and those usually took place in mornings or early evenings from four to six p.m. They wanted to have call lights answered promptly for all residents. Review of the following call light audit for resident 44 from 1/14/20 through [DATE] revealed the following wait times: 1/14/20, 7:08 a.m. : 35 minutes (min). 1/14/20, 8:45 a.m. : 44 min. 1/18/20, 7:54 a.m. : 42 min. 1/22/20, 8:51 a.m. : 33 min. [DATE], 4:25 p.m. : 31 min. 1/29/20, 8:38 p.m. : 42 min. 2/3/20, 8:24 p.m. : 33 min. 2/6/20, 8:17 a.m. : 31 min. [DATE], 7:04 a.m. : 33 min. [DATE], 7:52 p.m. : 43 min. 2/18/20, 10:30 a.m. : 44 min. [DATE], 9:56 a.m. : 33 min. Review of the provider's admission packet that included: Each resident must receive-and the facility must provide-the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the residents' person-centered plan of care. You are entitled to reasonable quality of life including: -To be treated with consideration, respect, and dignity. Recognition of your, and every resident's individuality.	2020-09-01
109	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	657	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor Based on observation, interview, record review, and policy review, the provider failed to review and revise care plans to reflect current needs of two of twenty-four sampled residents ([AGE] and 123). Findings include: 1. Review of resident 123's medical record revealed: She had been admitted on [DATE]. She had two pressure ulcers on admission. She had a history of [REDACTED]. She had a previous admission on 6/6/19 with pressure injuries and had been discharged on [DATE] without pressure injuries. She had a history of [REDACTED]. She also had two facility acquired pressure ulcers that had developed on 9/6/19 and 1/20/20. Review of resident 123's short term care plan with a date of 8/20/19 through 2/24/20 revealed: Several documented skin alterations, including the two facility acquired pressure ulcers. One notation of refusal of the pressure reducing device on her bed. There had been no interventions regarding positioning or incontinence care. Review of resident 123's care plan [DATE] for skin integrity revealed: Goal: Intact skin, but the focus was not clearly defined. Goal for: intact skin, free of redness, blisters or discoloration by/through review date 5/4/20. -It also indicated she was at risk for unavoidable altered skin integrity due to several factors. No revisions for interventions after she acquired two pressure ulcers while in the facility. The only intervention that was specific to the resident referred to the medication administration record (MAR) and treatment administration record (TAR); initiation date [DATE]. The care plan did not reveal she had pressure ulcers that had occurred while she was in the facility. Focus: (name) has bladder incontinence r/t (related to) needing staff assist with her toileting tasks. -Goal was: Remain free from skin breakdown due to incontinence and brief use. -Interventions were: --Check as required for incontinence. --Monitor/document/report PRN (as necessary) any possible causes of incontinence. Review of 2/27/20 physician orders [REDACTED].>Her diet did not mention added protein to assist in wound healing as mentioned on the care plan. There had been no orders referencing scheduled treatments to prevent issues with her skin. 2. Interview on 2/27/20 at 8:40 a.m with registered nurse (RN)/MDS coordinator T and RN/MDS coordinator U regarding residents' care plans revealed: They did MDS assessments quarterly, and then the care plans would be implemented, and started. When a new area of concern was identified they were contacted by ADON J or DON A to let them know changes were needed. The nurses from the floors wrote any new information on the short term care plans regarding the residents. -Those were kept in a binder at each nurses station for the staff to refer to. The MDS coordinators would then carry over that information to the the care plan and update it. -The unit managers did the updates from the locked units such as the memory care units. New interventions would be added on the regular care plans on a quarterly basis. If they got a physician order [REDACTED]. The nurses reported to the CNAs, and the new information is kept on a clipboard for them to review. The CNAs knew to look at it for changes. Interview on 2/27/20 at 11:11 a.m. with DON A regarding care plans revealed: They used short term care plans on the floor. -The information on those short term care plans might or might not be added to the care plan depending if it was still relevant at the time of the quarterly MDS assessment. She agreed their policy had been the care plans should have been updated to include relevant history or updates at least on a quarterly basis for residents. 3. Observations, record review, and staff interviews regarding to resident [AGE] during the survey revealed she had frequent fluctuations with weight changes and an overall weight loss between [DATE] and 1/17/20. Refer to F692, finding 1. Review of resident [AGE]'s 8/21/19 comprehensive care plan revealed: Focus: Diabetes. Goal: Stable weight. Interventions: -Likes ice cream, peas, beans, white bread, spaghetti, decaf coffee, water with ice, apple juice. Preferences noted on card. Will add snack in the afternoon to help prevent [DIAGNOSES REDACTED]. -Tried Magic cup on am snack cart-does not like. Date initiated: 7/30/19 with a revision on 10/16/19. No focus area with interventions and goals in place to support her weight loss, significant weight changes, and current nutritional needs. Interview on 2/26/20 at 10:35 a.m. with registered dietician (RD) W regarding resident [AGE] revealed: She confirmed the care plan was not complete nor was it reviewed and revised to support: -Her current needs for a more enhanced diet. -Interventions and goals specific to her weight loss concerns. -A nutritional plan had been developed that was specific to her needs. She was responsible for initiating, reviewing, and revising the dietary care plan for the residents. Interview on 2/26/20 at 2:27 p.m. with director of nursing (DON) A regarding resident [AGE] confirmed her care plan had not been updated and revised to reflect her dietary, nutritional, and weight loss concerns. Review of the provider's revised July 2017 Care Plan policy revealed: At (name) long term care plans are developed by an interdisciplinary team (IDT) with input and participation of CNA's, the resident, family and/or legal representative (when available). Prior to admission an assessment referral and initial care plan is completed. Care plans are written by exception and include measurable outcomes and identify interventions that are specific to the individual resident with defined time frames or parameters. Target dates are for 90 days unless otherwise specified. -Elements of the care plan include: --Short term care plan --Active and historical diagnosis --Current physician orders --CNA flow sheet --Restorative flow sheet, if applicable --PT/OT/ST, if applicable --MAR and TAR --Diet card The care plan is reviewed and/or revised after each assessment and PRN (as needed). The short term care plan is reviewed during this time and long term issues are carried forward to the long term care plan. *Pressure ulcer risk history section of this policy revealed: -All residents admitted to (provider name) are considered at risk of developing pressure ulcers. -All residents have pressure relieving or reducing mattresses on their beds as well as pressure relieving or reducing cushions on their chairs unless otherwise specified on the individualized care plans. -All residents admitted to (provider name) are offered to be repositioned at least every two-three hours unless otherwise specified on the individualized care plan.	2020-09-01
110	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	658	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, manufacturer's recommendations review, and policy review, the provider failed to ensure a high risk medication was administered according to the manufacturer's instructions for one of one randomly observed resident's (50) [MED] given by one of one registered nurse (RN) (H). Findings include: 1. Observation, record review, and interview on 2/25/20 at 4:49 p.m. of resident 50's [MED] administration by RN H revealed: The resident received [MEDICATION NAME] 70/30 [MED] 25 units scheduled and [MEDICATION NAME] R [MED] 4 units according to her sliding scale dosing. The [MEDICATION NAME] 70/30 was in a vial and was a cloudy colored [MED]. The [MEDICATION NAME] R was in a separate vial and was clear colored. RN H drew up the 25 unit dose from the [MEDICATION NAME] 70/30 vial first, and then drew up the 4 units of [MEDICATION NAME] R into that same syringe. She then administered the above [MED] injection into the resident's upper left abdomen. RN H indicated the above process was her usual practice to draw up and administer the [MED] when the resident required the sliding scale [MED] along with her scheduled dose. Interview and record review on 2/26/20 at 9:08 a.m. with licensed practical nurse I regarding resident 50's [MED] administration revealed:She had worked there for several years and usually worked on resident 50's unit. She had given the resident's [MED] many times in the past. When discussing her process for the resident's [MED] administration she indicated she would have: -Put both the [MEDICATION NAME] 70/30 and the [MEDICATION NAME] R into the same syringe. -Drawn up the [MEDICATION NAME] R first and then the 70/30. She thought the clear [MED] should have been drawn up first and not the cloudy. She felt it was okay to put both those [MED]s into the same syringe until questioned by the surveyor. When asked how she could verify giving the two [MED]s together she got a copy of the provider's Nursing 2018 Drug Handbook at the nursing station and reviewed it with the surveyor. That book revealed: -The above [MED]s should not have been put together into one syringe. -The instructions on page [AGE]2 for [MEDICATION NAME] 70/30 [MED] administration included: Don't mix with other [MED]s. She stated she had been mixing the two [MED]s for a long time, and she felt other nurses had been too. She had been taught to put the clear [MED] into the syringe first when putting more than one [MED] into the same syringe. -She had not known 70/30 [MED] should not have been mixed with regular. Interview on 2/26/20 at 1:56 p.m. with RN/staff development director C regarding the above concern revealed:She confirmed the nurses should not have put both [MED]s into the same syringe if the manufacturer's instructions had indicated not to. -That would have been considered a medication error. She had not been aware the nurses had been putting resident 50's [MEDICATION NAME] 70/30 and R [MED]s into the same syringe when she needed sliding scale [MED] along with her scheduled dose. She indicated there was no policy for [MED] administration. -The expectation would have been to follow the manufacturer's instructions for use. Interview on 2/26/20 at 2:23 p.m. with assistant director of nursing J regarding the above concern revealed:She had been taught to draw up the clear [MED] before the cloudy when putting [MED]s into the same syringe. -That would have been the [MEDICATION NAME] R first and then the [MEDICATION NAME] 70/30. She had not been aware the Drug Handbook indicated not to mix 70/30 [MED] with any other kind of [MED]. She had called their consultant pharmacist to clarify the [MED] mixing after she had been asked by the nurse this morning. -The pharmacist confirmed the nurses should not have been putting the above [MED]s into the same syringe. Review of the provider's revised September 2018 Medication Administration policy revealed:An accurate and safe method of administering medications will be carried out. 4. If unfamiliar with the med, check in the drug handbook, call the Pharmacist and/or physician for clarification or look for manufacturer guidelines if it is a recently released med. *7. Check for any special instructions the medication has for administration.	2020-09-01
111	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	686	E	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to appropriately implement, monitor, and alter care for three of six sampled residents (21, 118, and 123) who had multiple co-morbidities and were at risk for pressure ulcer/pressure injury development. Findings include: 1. Review of the provider's July 2017 Care Plan, Resident-Centered Facility Standards revealed: Care plans are written by exception and includes measurable outcomes and identify interventions that are specific to the individual resident with defined time frames or parameters. Pressure ulcer risk history section of policy revealed: -All residents admitted to (provider name) are considered at risk of developing pressure ulcers. -All residents have pressure relieving or reducing mattresses on their beds as well as pressure relieving or reducing cushions on their chairs unless otherwise specified on the individualized care plans. -All residents admitted to (provider name) are offered to be repositioned at least every two-three hours unless otherwise specified on the individualized care plan. Review of the provider's June 2018 policy for Pressure Sores Prediction and Prevention revealed: Policy: It is the responsibility of the Nursing staff at (provider name) to identify residents at risk, initiate preventive measures, and exercise early identification and treatment when noted. The four most critical factors that place our residents at risk are: -Pressure over a bony prominence. -Shearing-occurs when layers of tissue slide over each other. -Friction-occurs when two surfaces move against each other (as when a resident is slid in bed). -Moisture-leads to breakdown of the skin which enhances the risk of ulceration. This can be from urine, feces, perspiration or exudates (drainage). To identify specific residents at risk, an initial assessment will be done with each admission referral and interventions put in place as indicated. Review of the provider's June 2018 Pressure Ulcer policy revealed: No documentation of steps to take if pressure ulcer worsened. It did not address determining if current interventions or treatments were effective. 2. Review of resident 118's medical record revealed: She had been admitted on [DATE]. She had [DIAGNOSES REDACTED]. On 2/24/20, her Brief Interview for Mental Status (BI[CONDITION]) score was fifteen, indicating no cognitive deficit. She was non-ambulatory and used a wheelchair to move around the facility. She required extensive assistance of two staff to transfer and extensive assistance of one staff person for movement on and off of the unit, for dressing, toilet use, and personal hygiene. She had a fall on 5/24/19 that resulted in a femur fracture that prompted the need for an immobilizer on her right leg. Further review of resident 118's medical record revealed: A 6/3/19 pain assessment had been completed. -Resident reported frequent pain in the past five days which made it hard for her to sleep at night. She had rated her pain a ten on a scale of zero to ten with ten being the worst. A 6/4/19 nursing assessment noted no alteration in skin integrity. -Skin on heel had been discolored, very dry, and [MEDICATION NAME] cream had been applied. On 6/5/19 staff discovered an unstageable pressure ulcer on her right lower calf that had been under an immobilizer device to stabilize her leg. Observation and interview on 2/25/20 at 8:01 a.m. with resident 118 revealed: She had been resting in her recliner with her feet down. She did not have a bed in her room and preferred to sleep in her recliner. She had not been wearing a heel protector but did have ace wraps on both of her lower legs as ordered. -The heel protector was sitting on top of her dresser. There had not been pillows or protection under her heel or to the back of her right leg to keep pressure off of the area. She stated she did not like to wear the heel protector and preferred to wear gripper socks. Observation and interview on 2/25/20 at 9:59 a.m. and 2/26/20 at 1:55 p.m. with resident 118's daughter revealed: The resident was resting in her w/c with gripper socks on. She had no pillows or protection under her left heel or the back of her right leg. Her mother had not liked to wear the heel protector on her right foot and refused to wear it. Review of weekly wound observation assessment completed on 6/5/19 for resident 118 revealed: The wound was an unstaged, acquired pressure ulcer that measured 55 millimeters (mm) long x 70 mm wide. Infection had been suspected with redness noted and an odor. -Treatment included: Curad sterile dressing with a Biatin non-adhesive 4x4 over the area. Sheep skin boot over the area. Immobilizer was replaced. -Special equipment/preventative measures included: Reduce air loss pad to bed, padding placed at the site of the wound. Fax sent to physician on 6/7/19: resident has blood blister size of golf ball that is oozing out on inner side. (Facility name) wound nurse assessed and think maybe she should see wound care. Review of resident 118's physician's orders [REDACTED]. Skin Assessment (Medicare 14-day). Do a head-to-toe assessment and document if res (resident) has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, every shift until 6/12/19. [ENTITY]t date 5/31/19. -Nursing staff had not documented/initialed those orders had been followed on the TAR. Monitor C[CONDITION] (circulation, motion and sensitivity) Rt L/E (right lower extremity) every shift for Rt L/E fx (fracture) while using brace. [ENTITY]t date 6/3/19. -Nursing staff had initialed these orders had been followed on the TAR. Monitor for pain r/t (related to) Rt L/E fx every shift for Rt L/e fx until healed. [ENTITY]t date 6/3/19. -Nursing staff had initialed those orders had been followed on the TAR. Monitor skin condition Rt L/E fx every shift for Rt L/E fx while brace is in use. [ENTITY]t date 6/3/19. -Nursing staff had initialed these orders had been followed on the TAR. Wear bilateral heel lift boots at all times. Every shift for prevention. [ENTITY]t date 6/14/19. -Nursing staff had initialed those orders had been followed on the TAR. -No refusals had been documented on the TAR. Review of a weekly wound observation assessment on 6/19/19 for resident 118 revealed: The wound was an unstaged, acquired pressure ulcer. It measured 55 mm long x 70 mm wide, and no depth was recorded. -Preventative measures included: heel lift boots. Review of nursing notes on 7/22/19 revealed a second pressure ulcer had been discovered by nursing staff on resident 118's right heel and revealed: A 7/22/19 weekly wound assessment had identified the area as an acquired, stage II pressure ulcer by the wound clinic nurse. The wound measured 20 mm long x 25 mm wide and was 1 mm deep. -Preventative measures: heel lift boots and cushion in chairs. --That had not been a change from prior interventions. A 8/7/19 weekly wound assessment was completed after wound clinic physician visit had identified the area as an acquired, stage IV pressure ulcer. -The wound measured 40 mm in long x 54 mm wide with no depth noted. -Special equipment/preventative measure: heel lift boots and cushion in chair. The short term care plan had not included interventions for CNAs to follow to take pressure off the wound when it had been discovered on 6/5/19. Review of the 9/17/19 wound clinic physician's notes regarding resident 118 revealed: A severe ulcer of right leg near the ankle. Discussed amputation options with resident and her daughter regarding pressure ulcer. -The resident was not willing to consider amputation. Review of resident 118's care plan revealed: Goal initiated 1/9/19 and revised on 8/28/19: (Name) pressure ulcers will heal and her skin will be clean and intact skin by the review date. Interventions: -(Name) has developed pressure ulcers to her right calf and heel. (Name) was going to the wound clinic for treatment but is now being treated in house per wound specialist recommendations/doctor's orders. Staff will monitor and document wound per (facility initials) protocol. Initiated 6/7/19 and revised on 1/28/20. -(Name) has refused to wear slippers during the day and has been educated on the impact that could cause to her right foot. She has chosen to continue to wear her gripper socks/shoes throughout the day. Initiated 1/9/19 and revised on 1/28/20. -Follow orders for treatment of [REDACTED]. -Keep skin clean and dry. Use lotion on dry skin. Initiated 1/9/19 and revised 1/9/19. -Monitor/document location, size, and treatment of [REDACTED]. to MD. Initiated 1/9/19. -Staff will reposition (Name) per care plan standard or as (name) allows (she does at times refuse). (Name) has a pressure reducing w/c (wheelchair) cushion; to help heal and prevent additional skin breakdown. (Name) has been refused a bed in her room; (Name) has been educated on the potential benefits of sleeping in a bed and she prefers to sleep in her recliner, she does have a hx (history) of refusing to transfer into her recliner for sleep. Initiated 6/7/19 and revised on 1/28/20. The resident had refused to wear a boot protector, but nothing new had been trialed to replace it. Interview on 2/26/20 at 9:20 a.m. with CNA Q regarding resident 118's care revealed: She did not have a bed in her room and preferred to sleep in her recliner. They tried to have her keep her feet elevated when in the recliner. They floated her heels with three pillows. When she is in her w/c they cued her to keep her feet well placed. -She had a habit of resting the back of her heel against the foot pedal of the w/c that was where her injury was located. They tried to watch for that and reposition her. She had refused to wear the heel boot protector and wore slipper socks. They tried to reposition her every two hours. -She had refused assistance at times and they documented the refusals. Interview on 2/26/20 at 11:08 a.m. with assistant director of nursing J and registered nurse (RN)/staff development C regarding resident 118 revealed: They had assessed the wound on 6/5/19, and the resident had seen a physician at the wound care clinic on 6/14/19. The resident had developed a second pressure ulcer to her heel. They had tried a [DEVICE], but the resident had not tolerated it well. Stated her physician had later discussed amputation with the resident, but she had refused. She continued to be seen at the wound clinic every month or more often if needed. They continued to do dressing changes with cast padding and Ace wraps to protect the area. Agreed it had been a real problem, but the wounds had made some improvements. Interview on 2/26/20 at 1:54 p.m. with licensed practical nurse (LPN) CC regarding resident 118 revealed: She was familiar with the resident's needs and history. Confirmed the expectation had been for staff to remove the resident's immobilizer to complete a skin assessment then initial on the TAR. Stated she had removed the immobilizer to complete skin assessments. She remembered when the pressure ulcer had been discovered, and she had issues with pain. The wound had been a blister that had popped, but the skin was still covering it -She thought the pain was related to the fracture and did not think there had been a skin injury that had caused pain. The resident did not specify the location of pain under the immobilizer. She was unsure why the pressure injury had gotten so bad if assessments were being done as ordered. She currently had Ace wraps on both legs for issues with [MEDICAL CONDITION] and also to protect the areas. 3. Review of resident 21's medical record revealed: She had been admitted on [DATE]. She had [DIAGNOSES REDACTED]. She had developed a pressure injury to her left posterior upper thigh area that had been discovered on 7/14/19. On [DATE] annual MDS assessment revealed: -A BI[CONDITION] score of fifteen indicating no cognitive deficit. -She was non-ambulatory and used a wheelchair to move about the facility. -She required extensive assistance of one staff person with bed mobility to reposition, transfer, dress, and for toilet use. -She depended on staff to develop and implement interventions to prevent her from pressure injuries. Observation and interview on 2/25/20 at 9:49 a.m. and on 2/25/20 at 10:39 a.m. with resident 21 revealed: She was resting in a recliner with her legs up. There was no pressure relieving cushion on the seat of her recliner. She had an air mattress and used a cushion in her w/c. If she used her electric scooter she moved the cushion to her scooter seat. She was not able to reposition herself to relieve pressure on her bottom. At night she used her call light to alert staff that she needed to be repositioned. -Staff came about every three hours, and she preferred they not wake her up to reposition her. She stayed in her w/c after she got up in the morning and rested in her recliner with her legs up after lunch. Review of resident 21's care plan revealed: Goal initiated 5/1/18 and revised on 12/26/19: (Name) will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: -APP (alternating pressure pad) is being used on (Name) bed to help prevent skin alterations. (Name) does prefer to sleep/rest in her recliner. Initiated 5/1/18 and revised 10/24/19. -Follow MAR/TAR (medication administration record/treatment administration record) for any current treatments and monitor for healing. Initiated 5/1/18 and revised on 5/1/18. -Pressure reducing cushion is used to help prevent skin alterations. Initiated 5/1/18 and revised 10/24/19. -Staff will repo (reposition) (Name) per the Care Plan Standard or as (Name) allows. Initiated 5/1/18 and revised 1/28/20. Further review of the short term care plan revealed it had not specifed interventions for the CNAs to follow to reduce pressure off the wound after it had been discovered on 7/22/19. Interview on 2/26/20 at 8:39 a.m. with ADON J regarding the use of Braden assessment scale for identifying residents who were at risk of developing pressure ulcers revealed: They did not use the Braden scale assessment or any type of assessment tool. -They had considered all residents as high risk and put preventative interventions on all the care plans. All residents had a cushion in their chair, and a pressure reducing mattress to prevent pressure injuries. Interview on 2/26/20 at 11:02 a.m. with ADON J and RN/staff development C regarding resident 21 revealed: They were responsible for wound care for all of the residents of the facility. The resident had the wound since 7/15/19. It had been difficult to get the resident off the area since she participated in several activities while seated in her w/c. And she often sat in her recliner. A cushion had been used for her w/c and scooter, and she had an air mattress on her bed. They had educated her on the need to reposition and offload that area. They had tried Z-guard barrier cream, a wound gel with collagen powder, collagen powder alone, and had considered electrical stimulation to the area to promote healing. A wound specialist had seen the resident for the past three or four months. The wound was healing. Interview on 2/27/20 at 9:21 a.m. with CNA Q regarding resident 21 revealed: She had worked with her and was familiar with her care. The CNAs used the short term care plan and the report from the nursing staff to be informed of changes. -They also used a clip board with information about the resident's care that was at the nurses station. -That was how they knew what to do for care of the residents. The resident could not reposition on her own. -She was repositioned every two to three hours. -If she had been with visitors she would not allow it. Review of resident 21's 7/22/19 weekly wound assessment revealed: A stage II acquired pressure ulcer on her right posterior thigh. It measured 40 mm long x 35 mm wide with no depth documented. Review of resident 21's 2/25/20 weekly wound assessment revealed: A stage III acquired, pressure ulcer in the same location, and they noted it was worsening. It measured 20 mm long x 9 mm wide with no depth documented. 4. Interview on 2/27/20 at 11:11 a.m. with DON A regarding residents 118 and 21 revealed: They continued to look at pressure ulcers at the facility. All residents had a cushion in their chair, and a pressure reducing mattress to prevent pressure injuries from occurring. -Those interventions had not prevented skin breakdown. -She believed that resident 118's injury was not preventable due to her diabetes and vascular issues. -She thought the achilles wound on resident 118 was a deep tissue injury that continued down to the heel area. --She believed the nursing staff had followed orders, done skin assessments, and removed the immobilizer. -Stated the resident had refused to sleep in a bed which complicated things, and they would continue to encourage her to do so. -They had interventions in place such as putting pillows under her legs while she was in her recliner. The facility documentation stated it was an acquired pressure ulcer, and the use of pillows was not mentioned on the short term care plan or comprehensive care plan. Regarding resident 21: -She spent a lot of time with her husband and out of her room. -The resident was often seated in her w/c or recliner and it was difficult for staff to offload the area. -The CNAs repositioned her whenever possible. -They had interventions of a cushion in her chair and an air mattress on her bed. Surveyor 5. Review of resident 123's medical record revealed: She had been admitted on [DATE] with two pressure ulcers. Her [DIAGNOSES REDACTED]. On 11/12/19, her BI[CONDITION] assessment score was thirteen, indicating no significant cognitive deficit. Minimum Data Set (MDS) quarterly assessments on 11/12/19 and 2/4/20 revealed she did not reject care and ambulated with one staff person. On 9/6/19, she had developed a stage two pressure ulcer on her left posterior thigh. On 1/20/20, she had developed a stage two pressure ulcer on her left buttock. -It was later indicated as a stage three pressure ulcer. Random observations between 2/26/20 and 2/27/20 of resident 123 revealed she was sitting in her recliner with pressure reducing cushion on her chair. Interview on 2/26/20 at 1:45 p.m. with resident 123 revealed she would refuse to move if she was in pain. Interview on 2/26/20 at 5:39 p.m. with ADON J revealed: All residents were considered high risk for pressure ulcers. They did not use Braden scale (assessment) to determine the risk of developing a pressure ulcer for an individual. All residents got pressure relieving devices. There was no tool used to determine if one resident was at a higher risk than another. Interview on 2/27/20 at 10:13 a.m. with the DON A and RN/staff development director/wound care nurse C revealed: Resident 123's pressure ulcer had been caused by sitting in one place for too long, at one time, and moisture. A moisture barrier cream was started after the pressure ulcer was identified on [DATE]. -They considered this intervention effective because between September and January she did not get any pressure ulcers. -There were no changes with her interventions after she acquired another pressure ulcer in January 2020. -Review of resident 123's 11/19/19 care plan revealed no interventions for repositioning or how to respond to refusals. Resident had often refused to reposition herself or allow staff members to assist her to the toilet, or to reposition. They had accepted her refusal but had not attempted to identify precipitating factors such as pain. They did not use the Braden scale or any other skin assessment scale for documenting pressure ulcer risk. Interview on 2/27/20 at 12:03 p.m. with the medical director revealed he: Had been the medical director for the previous year. Attended monthly quality assurance process improvement meetings. Agreed if interventions were not working other approaches should have been tried with residents. Was not aware of benchmarks for pressure ulcers, they were reviewed on a case by case basis versus systemic review. The meetings were used as a reporting tool for the different disciplines. They talked about interventions and new ideas, but usually there had been nothing more that could be done. Agreed that it would be an expectation for staff to remove an immobilizer to do skin assessments. Agreed if a resident had been in pain, treat the pain, and then staff should come back and look for what could have caused the pain. Confirmed resident 21 sat a lot, and it was difficult for staff to assist her to offload. Agreed if there were refusals they should have tried other things and to include all disciplines. Agreed the facility needed to improve documentation because they documented some data in a paper chart and some electronically.	2020-09-01
112	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	692	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure: The nutritional status was monitored for one of three sampled residents ([AGE]) who had a significant weight loss and was nutritionally at risk. Nutritional intakes had been monitored for one of three sampled residents ([AGE]) who had a medication change to help increase her appetite. Findings include: 1. Observation and interview on 2/24/20 at 5:06 p.m. with resident [AGE] revealed she had: Been laying in her bed resting. Appeared very thin and frail with her bones easily visualized through her skin. Required the use of oxygen and became short-of-breath when talking to the surveyor. Been alert and able to voice her concerns without difficulty. Spent the majority of her days in her room. Stated: -Why would I want to go out there? -Who are you and just what do you want anyway? -You must be in on it. -And meals? No, I eat in my room. Review of resident [AGE]'s medical record revealed: An admission date of [DATE]. Her [DIAGNOSES REDACTED]. She required staff support of one person for all activities of daily living (ADL). -That had included bed mobility, transfers, walking, dressing, and personal hygiene. She: -Frequently refused assistance from the staff with those ADLs. -Was able to eat independently after the staff had set it up for her. -Was dependent on the staff to develop and implement a plan of care for her. -Was seen by telehealth and another counseling institute to monitor the stability of her mental health. -Chose to spend a majority of her time in her room. Her level of confusion fluctuated from day-to-day. She had: -A history of making unsafe choices for herself that had impacted her weight and nutritional health. -Frequently refused to have her weight monitored to ensure any concerns had been appropriately monitored and treated in a timely manner. -History of non-compliance with taking her medication. Review of resident [AGE]'s weight record revealed on the following: 11/20/19: 116 pounds (lb). [DATE]: 116.5 lb. 1/17/20: 106 lb. indicating a 3 percent (%) weight loss since [DATE]. 1/24/20: 104.5 lb. indicating a 5% weight loss since [DATE]. 2/14/20: 104 lb. indicating a 7.5% weight loss since 11/20/19. Review of resident [AGE]'s progress notes revealed: There were none from the registered dietician (RD) during those above weight record times. -The last nutrition/dietary note by the RD had been on 10/16/19. On 1/22/20 the dietary manager (DM) had completed a quarterly review for the assessment reference date of 1/14/20. There was no further nutrition/dietary documentation from the RD or DM after 1/22/20. Review of resident [AGE]'s 8/21/19 comprehensive care plan revealed: Focus: Diabetes. Goal: Stable weight. Interventions: -Likes ice cream, peas, beans, white bread, spaghetti, decaf coffee, water with ice, apple juice. Preferences noted on card. Will add snack in the afternoon to help prevent [DIAGNOSES REDACTED]. -Tried Magic cup on am snack cart-does not like. Date initiated: 7/30/19 with a revision on 10/16/19. No focus area with interventions and goals in place to support her weight loss, significant weight changes, and current nutritional needs. Review of resident [AGE]'s physicians' orders revealed on: 1/24/20: she had been seen by her primary physician for a sixty day update. -There was no documentation to support she had been assessed by the physician for a 5% weight loss. [DATE]: The telehealth physician had increased her [MEDICATION NAME] for her depression and appetite concerns. -There was no documentation to support what appetite concerns had been reviewed for her. Review of resident [AGE]'s 11/19/19 through 2/25/20 nursing progress notes revealed no documentation to support: Her weights had been monitored and reported to the RD, DM, and physician. She refused to be weighed more than once a month. She had an appointment on [DATE] with telehealth, and her medication was changed. The dietary department was notified of those medication changes to help with her appetite. Her meal intakes had been monitored after the change in her medication to support: -Acceptance and toleration of the increased dosage. -Whether her appetite had improved or not. Interview on 2/26/20 at 10:35 a.m. with RD W, CNA X, and LPN Z regarding resident [AGE] revealed: She had: -A history of fluid retention due to (d/t) her non-compliance with taking her diuretic medication. -A tendency to isolate herself in her room and preferred to eat her meals there. That had made it difficult to monitor her nutritional intakes. -Very specific likes and dislikes for certain foods, and they tried to accommodate those preferences as much as possible. She was scheduled for a weekly bath and weight every Wednesday. -Frequently she had refused those baths and weights. The staff were to have informed the charge nurse with any weight discrepancies of 3 lbs. -A re-weight should have been completed that same day. -She had frequently refused those attempts to re-weigh her. RD W and LPN Z had not been aware of her: -Significant weight loss from [DATE] through out 1/17/20. -Appointment with telehealth on [DATE] and the medication changes from that appointment to help with her appetite. They agreed: -She was considered nutritionally at risk for weight loss and should have been monitored closer. -Her nutritional intakes, weights, and toleration of that dosage change should have been monitored and assessed by both the nursing and dietary departments. The RD and DM tried to review the resident's weights weekly and communicate with nursing when a change or concern was identified. -They agreed that had not occurred for her and should have. The RD confirmed the care plan was not complete nor was it reviewed and revised to support: -Her current needs for a more enhanced diet. -Interventions and goals specific to her weight loss concerns. -A nutritional plan had been developed that was specific to her needs. The RD was responsible for initiating, reviewing, and revising the dietary care plan for the residents. Interview on 2/26/20 at 2:27 p.m. with director of nursing (DON) A regarding resident [AGE] revealed: She confirmed the above medical record review on the resident. She agreed: -Documentation by both the nursing and dietary departments had not supported appropriate monitoring and assessing of a resident who was at risk for a weight loss. -Intakes should have been completed and monitored on a resident who had a medication change to help increase their appetite. Review of the provider's undated and unsigned Significant Weight Changes policy revealed: Resident with significant weight changes are reported to the care team on a regular basis. Interventions may include: -Assessing risk factors that may affect the change. -Reweighing the resident for accuracy. -Identifying what nutrition plan may be effective for that person. -Documenting findings in the medical record. -Doing a detailed food intake. -Reviewing the care plan. -Adjusting the nutritional plan. -Notifying the physician and family. -Adjusting the times/week a resident is weighed.	2020-09-01
113	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	838	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure the facility assessment had addressed the staffing resources needed to ensure appropriate care and services were available to the residents. Findings include: 1. Review of the provider's 8/20/19 facility assessment revealed: Their resources for staffing needs had not been addressed. The assessment was eighteen pages long, and it included: -An overview indicating it was a 162-bed skilled nursing facility licensed by the State of [STATE] and certified by both the Medicare and Medicaid programs. -Services offered were: skilled nursing care and professional physical, occupational, and speech therapy services for both inpatient and outpatients. -The resident capacity was 162 with the current number of residents at 148. --The overall acuity of residents was left blank. -A listing of the total number of employee positions for administration and staff. --It had not specified how many staff were needed to care for the residents or how they would have been scheduled/assigned. -A listing of totals for resident diagnoses. --It had not specified how those [DIAGNOSES REDACTED]. -Eight of the sixteen pages listed physical environment and equipment within the building. -A listing of services provided by contract with a plan for annual reviews of them. -A listing of competency-based training for staff. -A page of health information managing and sharing. -A page for facility-based and community based risk assessment annual reviews. There had been no mention of: -The facilities multi-level, multi-unit layout that included seven distinct nursing units. --Three of those seven were memory care units. -The third floor having more residents overall with higher level of care needs. -The usual amount of assistance required by the residents based on their medical and mental health diagnoses. -How the facility would have been staffed to ensure the residents' care needs were being met. Interview and facility assessment review on 2/27/20 at 7:57 a.m. with director of nursing A and administrator B revealed: They confirmed the assessment had not included and addressed their staffing needs. It listed all the staff they had, but it had not identified what staffing was needed to ensure appropriate care and services were available to the residents. They confirmed the facility was unique with having had three specific memory care units and four other nursing units within the three levels of the building. They agreed the third floor of the building had more residents and the increased level of care needs. The first floor memory care unit held residents with less care needs who were ambulatory. Interview and facility assessment review on 2/27/20 at 10:00 a.m. with quality assurance and therapy director K revealed:She assisted with the development of the facility assessment and the overall template for it. She confirmed the staffing needs were not addressed on their assessment. *There was no specific policy on the process for the facility assessment. -They would have followed the regulation.	2020-09-01
114	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	867	D	0	1	Q3ZW11	Based on interview and policy review, the provider failed to implement an effective quality assurance process improvement (QAPI) program that focused on improving systemic problems. Findings include: 1. Interview on 2/26/20 at 1:35 p.m. with QAPI director K revealed: The committee met every month, and there were fifteen committee members. They reviewed the indicators on the Certification and Survey Provider Enhanced Reporting system (CASPER) report that were over the [AGE]th percentile. There could be other items that were under that percentile discussed, but the main focus was the CASPER report. They had a process improvement plan (PIP) they were working on for decreasing antipsychotic medication (med) use to meet the goal of 15 percent reduction of that med. Pressure ulcers and falls were on the agenda every month with updates given by director of nursing (DON) A. -They did not have a PIP for those items. Several times during this interview when asked for clarification on falls and pressure ulcers she said she knew we were going to ask for data, but she did not have it in her QAPI notes. Interview on 2/27/20 at 9:26 a.m. with administrator B and assistant administrator N revealed there was a large group of individuals that attended the meetings each month. Also agreed the QAPI meetings had become more of a reporting system and not an improvement program. Interview on 2/27/20 at 10:13 a.m. with DON A revealed she: Reported information on pressure ulcers and falls at the monthly QAPI meetings. Did not use a benchmark to determine the effectiveness of interventions or improvements. -Looked more at the individual than the system or overall trends. Did not have a system in place to effectively monitor trends. Focused on the resident versus systemic problems. Was unable to indicate how many pressure ulcers were facility acquired. Interview on 2/27/20 at 12:04 p.m. with medical director S regarding the QAPI meetings that he attended revealed he: Attended the meetings every month. When he asked for further details on key indicators he was given further information. Believed the information was able to be given verbally when asked for but perhaps it was not documented well. Stated in the meeting they talked about the issues. Review of the providers Quality Assurance and Performance Improvement (QAPI) policy that was undated but given at the time of this survey revealed: PURPOSE: The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, families and other partners so that we may realize our vision of meeting the physical, social and spiritual needs of the individuals we serve, with comfort and dignity.	2020-09-01
115	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	880	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions were maintained during personal care for 2 of 11 sampled residents (132 and 142) by one of one certified nursing assistant (CNA) (AA). Findings include: 1. Observation on 2/25/20 at 8:31 a.m. of CNA AA with resident 132 revealed: The resident had been in the bathroom waiting for assistance. He had required the use of a mechanical stand-aide for transfers and was already hooked-up to it. The CNA sanitized her hands and put on a clean pair of gloves prior to assisting the resident with personal care and a transfer. With those gloves on she: -Took a garbage bag off of a roll that had been on top of the glove box container. -Opened a dresser drawer and took out an incontinent brief and a bottle of perineal wash. -Touched the water faucet handle without using a barrier and turned on the water to wet a washcloth. -Assisted him with the mechanical stand-aide and raised it up to transfer him off of the toilet and provide personal care. With those now soiled gloves still on she took the washcloth, sprayed it with perineal cleanser, and provided perineal care for him. -She removed her gloves, put a clean incontinent brief on the resident, pulled up his pants, and transferred him to a recliner. Then washed her hands and left the room. 2. Observation on 2/25/20 at 1:03 p.m. of CNA AA with resident 142 revealed: The resident had been: -In her room sitting in a recliner. -Waiting for the CNA to assist her with a transfer, toileting, and personal care. She had required the use of a gait belt and a one person assistance for stand-pivot for transfers. The CNA sanitized her hands and put on a clean pair of gloves prior to assisting the resident with a transfer and personal care. With those gloves on she: -Put a gait belt around the resident's waist and transferred her to a wheelchair (w/c). -Opened the bathroom door and pushed the resident into the bathroom. -Assisted the resident to stand-up, pull down her pants, remove her soiled incontinent brief, and assisted her to sit down on the toilet. -Took a garbage bag off of a roll that had been on top of the glove box container and opened it. -Opened a cupboard door in the bathroom and took out a clean incontinent brief. -Touched the water faucet handle without using a barrier and turned on the water to wet a washcloth. -Assisted the resident to stand-up. With those now soiled gloves still on she took the washcloth, sprayed it with perineal cleanser, and provided perineal care for her. -She removed her gloves, put a clean incontinent brief on the resident, pulled up her pants, and transferred her into the w/c. Then washed her hands and left the room. 3. Interview on 2/25/20 at 1:21 p.m. with CNA AA regarding the above observations of personal care for residents 132 and 142 revealed: That had been her usual process for providing personal care for the residents. She stated: I put gloves on too soon. She had not recognized the process as unsanitary until after the observations were reviewed with her. She agreed: -The personal care provided above had not been completed in a sanitary manner and placed residents at risk for acquiring an infection. -She should have removed her gloves and washed or sanitized her hands after they had been soiled and prior to doing personal care. Interview on 2/26/20 at 1:06 p.m. with director of nursing A regarding the above observations revealed she: Agreed the personal care above was not completed in a sanitary manner. Agreed the process above had created the potential for the residents to have acquired an infection. The CNA should have removed her gloves and sanitized her hands anytime they had been soiled. Review of the provider's March 2016 Handwashing policy revealed: The spread of infection will be curbed by proper and frequent handwashing. Always wash hands: -Before and after contact with each resident. -After contact with soiled linen. -After contact with objects that have had resident contact and may be contaminated. -After caring for a resident or touching any items contaminated with spore-forming organisms such as [DIAGNOSES REDACTED] ([MEDICAL CONDITION]). A used or clean paper towel should have been used to turn the water faucet on and off. The faucet was considered dirty and would contaminate your hands.	2020-09-01
116	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2017-10-04	159	D	0	1	557P11	Based on interview, record review, and policy and review, the provider failed to ensure all residents' funds were in an interest bearing account for one of one resident trust fund account. Findings include: 1. Interview and record review on 10/4/17 from 10:00 a.m. through 10:45 a.m. with the staff accountant and assistant administrator regarding residents' trust funds revealed: There was one account containing residents' trust funds. The balance of the resident trust account was $8,935.97. The staff accountant reported the trust account had received no interest on that account since (MONTH) (YEAR). Both agreed the residents' trust funds were not in an interest bearing account. The assistant administrator agreed those funds needed to have been in an interest bearing account. Review of the provider's 10/4/17 Trust-Current Account Balance revealed: There were a total of forty-seven residents with a resident trust account. There were a total of thirty-two residents with a balance greater than $50.00. Review of the provider's (MONTH) (YEAR) Resident Trust Fund policy revealed: The provider offered each resident the opportunity to open a trust account. *All residents with monies in the residents' fund would have earned interest on the balance on the 17th day of each month.	2020-09-01
117	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2017-10-04	160	E	0	1	557P11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy and procedure review, the provider failed to return money belonging to five of five sampled deceased residents (25, 26, 27, 28, and 29) responsible party in the allotted time. Findings include: 1. Record review of the following deceased residents who had funds in the residents' trust funds account revealed: Resident 25 had died on [DATE] and $41.50 should have been returned to the resident's estate by [DATE]. If it had not been claimed the funds should have been sent to the state of South Dakota by [DATE]. - Nothing had been done with the funds. Resident 27 had died on [DATE] and $414.64 should have been returned to the resident's estate by [DATE]. If it had not been claimed the funds should have been sent to the state of South Dakota by [DATE]. -Nothing had been done with the funds. Resident 28 had died on [DATE] and $26.26 should have been returned to the resident's estate by [DATE]. If it had not been claimed the funds should have been sent to the state of South Dakota on [DATE]. -Nothing had been done with the funds. Resident 29 had died on [DATE] and $36.50 should have been returned to the resident's estate by [DATE]. -Nothing had been done with the funds. Resident 26 had died on [DATE] and $40.50 should have been returned to the resident's estate by [DATE]. -Nothing had been done with the funds. Interview and record review on [DATE] at 10:10 a.m. with the staff accountant regarding the above residents' trust funds revealed: She waited for the accounts received staff to let her know when to release the funds. She had not received permission for the above residents accounts to be released. She did not know there was an allotted time for those funds to be released. Interview on [DATE] at 10:30 a.m. with accounts received staff revealed: She was not aware of the accounts that had not been paid. She was not responsible for letting the staff accountant know when to release funds for every discharged or expired resident. Interview on [DATE] at 10:42 a.m. with the assistant administrator revealed: *He was not aware funds had not been returned to the residents' estates or the state of South Dakota. Review of the provider's (MONTH) (YEAR) Resident Trust Fund policy and procedure revealed they were to have promptly returned personal monies upon death or discharge to the appropriate party.	2020-09-01
118	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2017-10-04	441	E	0	1	557P11	Based on observation, interview, record review, and policy review, the provider failed to ensure: Appropriate infection control was followed for one of one sampled resident (1) by one of of one observed licensed practical nurse (LPN) (B) during one of one dressing change. Proper handwashing and glove use was followed for two of six sampled residents (1 and 10) by two of six certified nursing assistants (CNA) (A and H) during personal care. Appropriate infection control was followed for one of one sampled resident (10) by one of one CNA (H) during one of one observed catheter care. Linens were covered for one of one observation during transporting and delivery by one of one observed hospitality aide (E). Findings include: 1. Observation on 10/4/17 at 10:00 a.m. in resident 1's room with LPN B revealed: She performed hand hygiene, put on a pair of gloves, and then: -Set a spray bottle of wound cleanser on the floor beside the resident. -Without laying down a protective barrier on the dresser she began to place a package of 4x4's and a package of Meplex dressing on it. -The Meplex dressing fell to the floor. -Removed the old dressing from the resident's left shin area. -Opened the package of 4x4s. -Picked the wound cleanser bottle up off the floor and sprayed the 4x4s with it. -Cleaned the area on and around the wound sight. -Removed her gloves and performed hand hygiene. -Put on a new pair of gloves. -Picked the Meplex dressing package up off the floor. -Opened the Meplex dressing package, removed the dressing, and applied it to the resident's left shin wound area. Interview on 10/4/17 at 9:00 a.m. with the director of nursing (DON) regarding the above revealed her expectations would have been for LPN B to have: Not placed wound supplies on the floor. Discarded the Meplex dressing package that had fallen on the floor and should have obtained a new dressing. Review of the provider's (MONTH) 2014 Dressing Changes Clean Technique policy revealed: Dressing change will be done by a licensed nurse using Clean Technique unless otherwise stated by physician. -2. Assemble necessary equipment. --Include a clean surface on which to place supplies (i.e. clean hand towel) and a plastic bag for disposal. 2. Observation on 10/2/17 at 7:40 a.m. in resident 1's room with CNA A revealed: Without performing hand hygiene she: -Put on a pair of gloves. -Assisted the resident to transfer from the wheelchair to the toilet. -Removed a wet brief from the resident and discarded it into the garbage. -Removed her gloves. Without performing hand hygiene she: -Put on a pair of gloves. -Assisted the resident to stand up. -Performed perineal care. -Pulled up the resident's slacks. -Removed her gloves. Without performing hand hygiene she: -Assisted the resident to the wheelchair. -Placed the resident in front of the sink. -Handed the resident mouth wash and a drinking glass. Interview on 10/4/17 at 9:00 a.m. with the DON regarding the above revealed her expectations would have been for CNA A to have performed hand hygiene after removal of her gloves. Surveyor: 3. Observation on 10/3/17 at 7:40 a.m. of CNA H performing resident 10's personal care and catheter care revealed she:Put a pair of gloves on without washing her hands. Put the resident on the toilet. Obtained a wash cloth, turned the faucet on, wet the cloth, and gave it to the resident to wash his face. Removed his pants. Assisted him with putting a shirt on. Removed his socks and put clean socks on his feet. Continued observation of CNA H with the same gloves on revealed she: Emptied urine from the catheter bag into a graduate pitcher and used an alcohol wipe to clean the exit port of the bag. Removed a urinary collection leg bag from a plastic bag that had been attached to the grab bar. Transferred the catheter from the catheter bag to the leg bag and cleaned the catheter tubing with an alcohol wipe. Pulled the soiled brief off. Obtained a washcloth and washed his private areas. Put a clean brief on him and pulled up his pants. Removed her gloves and without washing her hands put on a pair of clean gloves. With those gloves on she: Obtained a toothbrush from the cabinet and set it up for the resident. Emptied the urine into the toilet. Closed the cabinet door. Placed soiled clothing into a bag. Replaced the toothbrush into the cabinet. At that time she removed her left glove and without washing her hand she: Picked up the bag containing the urine collection bag. Opened the door and walked to the soiled utility room. Removed the urine collection bag from the bag. Turned on the water faucet on the hopper. Held the tubing end and rinsed the collection bag with hot water. -The collection bag was touching the floor while the tubing was being filled. Emptied the water from the bag. Wrapped the tubing around the bag and placed the bag in a new bag. -There was no cap covering the tip of the tubing. It was only at that time that she wash her hands. Interview with CNA H at that time revealed: That was how she normally performed the personal care and catheter care for resident 10. There was no cap to cover the tip of the catheter bag tubing. She thought the nurses threw the covers away when they changed the bags. 4. Interview on 10/4/17 at 10:30 a.m. with registered nurse (RN) F and G regarding the above observed personal care and catheter care revealed: Both nurses were involved in the infection control program. Another nurse audited nursing staff for appropriate personal and catheter care. They were not sure why CNA H had rinsed the bag with hot water. The CNA should have washed her hands between soiled items and clean items. They confirmed the CNAs had not maintained a clean technique for personal care and catheter care. Review of the provider's (MONTH) (YEAR) Urinary Drainage Bags (leg bags) policy revealed: Urinary collection bags were to have been cleaned after each use prior to storage when catheter drainage bags (leg bags/bed bags) were used intermittently. The staff member was to have: -Washed hands and put gloves on prior to disconnecting the drainage bag from the catheter. -Wiped the end of the tubing with alcohol. -Taken the disconnected drainage bag to the resident's bathroom. -Flushed the bag with prepared vinegar/water solution. -Capped all tubing ends or tightened alcohol foil from wipes on the tips. -Placed the sanitized bag and tubing in a plastic bag in the bottom drawer of the bedside stand or in a cloth catheter bag and hang on the bar in the bathroom. Surveyor: Review of the provider's (MONTH) (YEAR) Handwashing policy revealed: Policy: The spread of infection will be curbed by proper and frequent handwashing. Responsibility: Nursing staff - To follow proper procedure and indications for handwashing. Instructions: 1. Always wash hands: -a. Before and after contact with each resident. -c. After contact with blood or body fluids. -g. After contact with objects that had resident contact and may be contaminated. -h. Between changing gloves. Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., (YEAR), pp 410 and 411, revealed: Contaminated hands of health care workers are a primary source of infection transmission in health care settings. The CDC (Center for Disease Control) (2002; WHO, 2009) recommends the following: -3. If hands are not visibly soiled (WHO, 2009), use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in the following clinical situations: --a. Before, after, and between direct patient (resident) care. --b. After contact with body fluids or excretions. --d. After contact with inanimate surfaces or objects in the patients room (eg., over-bed table). --g. After removing gloves. 5. Observation on 10/3/17 at 11:00 a.m. of hospitality aide [NAME] distributing linens and personal supplies on the second floor of building two revealed: The supply cart was in the hallway. The stainless steel cart doors were opened. The bottom of the cart contained tubes and bottles of personal toiletries. The upper area inside the cart contained incontinence briefs. The top of the cart contained clean linens including washcloths, towels, and residents' gowns. A large sheet hung on a bar on the side of the cart leaving the clean linens exposed. Interview at that time with hospitality aide [NAME] regarding transporting linens revealed: She had been delivering linens for approximately one year.She covered the linens with the sheet if she was wheeling it down the hall. She did not keep the linens covered if she was busy delivering the items to the residents' rooms. The sheet cover would get in the way of her delivering linens. That was how she had been instructed to deliver the linens and supplies. Interview on 10/4/17 at 10:30 a.m. with RN/infection control nurses F and G regarding linen delivery revealed their expectation was the linens were to have been covered. Review of the provider's undated Laundry/Linen Distribution policy revealed: Clean laundry carts were to have been used to transport clean laundry and linen. Clean linen was to remain covered during transportation to other areas.	2020-09-01
119	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	604	D	0	1	L4X311	Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing assessments and care planning were completed for one of one cognitively impaired sampled resident (19) who was using a recliner with his feet up without access to the chair remote control. Findings include: 1. Random observations on 12/10/18 from 4:10 p.m. through 7:00 p.m., 12/11/18 from 7:00 a.m. through 6:30 p.m., and 12/12/18 at 7:15 a.m. thru 5:00 p.m. of resident 19 revealed: He was sitting in his recliner with his feet up except for meals. When asked how to put his feet down he replied he did not know what to do. His wife, who was his roommate, responded he could not have his remote, because he messed around with them and broke them. His chair remote was pinned to the back of his recliner on the 12/10/18 and 12/11/18 observations. Interview on 12/12/18 at 10:06 a.m. with the director of nursing (DON) regarding resident 19 revealed: His wife had requested him to not have the remote for his chair. She was not aware of any remotes that have been damaged. She agreed his wife's wishes should have been documented and care planned. His wife would put her light on when he needed help. Observation on 12/12/18 at 10:15 a.m. and at 2:05 p.m. in resident 19's room revealed: His feet were up while sitting in his recliner. His remote cord was tucked into the side chair cushion while the remote control hung down the front of his chair. -He could not see the remote control in that position. His remote had a handwritten note on it do not give to (name). His wife was sleeping in her recliner at both times above. Observation and interview on 12/12/18 at 2:07 p.m. with licensed practical nurse (LPN) N in resident 19's room revealed: A note had been taped on his chair remote by his wife. She was sleeping in her recliner. LPN N stated staff had taken off those notes, but she kept putting them back on. His wife had been asking staff to not give him the remote for the chair for approximately six months. There was no mention of the remote being pinned on the chair on the care plan or any other documentation about the above. Interview on 12/12/18 at 2:35 p.m. with LPN L regarding resident 19 revealed: There was no mention of the remote being pinned on the chair on the care plan nor any documentation. She agreed they should probably have charted about his wife's request to not to give him the remote. Interview on 12/12/18 at 2:25 p.m. with Minimum Data Set (MDS)/LPN K revealed: She did not know resident 19 did not have access to his chair remote. She did not evaluate him in his room for his MDS assessment. His MDS assessment was in progress, and she had interviewed him last week. She agreed it would be considered a restraint if he did not have access to it. Interview on 12/12/18 at 2:49 p.m. with MDS/registered nurse (RN) [NAME] regarding resident 19 revealed: She had not been informed he had not been given access to his chair remote when his feet were elevated. Staff had not communicated with her his wife did not want him to use the remote. LPN K would have assessed the bed and surroundings during his MDS assessments. -She would have considered that a restraint. Review of the provider's (MONTH) 2000 Restraint policy revealed: After less restrictive measures have been tried, have been unsuccessful, and have been documented the use of physical restraints might have been considered. Staff would have needed to ensure to: -Assess the nurses notes and care plan to ensure that alternative measures had been attempted. -Obtain a physician's order for the restraint. -Notify the resident's family. -Document in the nurses notes and care plan. Review of the resident's complete medical record revealed: No restraint assessment. No mention of the resident not having access to his remote. No physician's order to support the use of a restraint. No mention of a restraint on his MDS assessment. *No family notification.	2020-09-01
120	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	657	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure 3 of 29 sampled residents (19, 104, and 114) had their care plans updated and revised to reflect their current status and care needs. Findings include: 1. Observation and interview on 12/11/18 at 12:01 p.m. with resident 114's wife revealed: He was in his room sitting in a rocking wheelchair (w/c). -He had been sitting on a pressure relieving cushion. The mattress on his bed had: -An alternating pressure pad on it. High edges on both sides of it. His wife had been in his room visiting and spending time with him. His wife confirmed he: -had a history of [REDACTED]. -Was dependent upon the staff to ensure all of his activities of daily living (ADL) had been met. -Currently had a red area on his bottom. Review of resident 114's 8/23/18 Admission Referral/Baseline Care Plan information revealed: He had a left hip contusion from a fall and was at risk for falls. No documentation to support he: -Had required a special mattress to help him identify the edges for safety. -Had been at high risk for skin breakdown and required pressure relieving devices. -Was dependent upon the staff to ensure all of his ADLs had been met including repositioning. Review of resident 114's 9/12/18 comprehensive care plan revealed: No documentation to support he required: -A special mattress to ensure his safety from falls had occurred. -Repositioning to ensure skin breakdown had not occurred. Pressure relieving devices were put in place prior to skin breakdown occurring. Interview on 12/12/18 at 2:20 p.m. with Minimum Data Set (MDS) assessment coordinators [NAME] and K regarding resident 114 revealed they: Were responsible for the initiating, reviewing, and revising of all the care plans. -The charge nurses would have been expected to update the resident's short-term care plans. Confirmed the direct caregivers would have used the comprehensive care plans to ensure the residents received the appropriate care and services. Confirmed his baseline and long-term care plans had not been developed and updated to reflect his current care needs and should have been. Interview on 12/12/18 at 3:10 p.m. with the director of nursing (DON) supported the above interview with the MDS assessment coordinators [NAME] and K. She would have expected his care plans to have reflected what his current care needs had been. Refer to F686, finding 2. 2. Observation and interview on 12/10/18 at 4:05 p.m. with licensed practical nurse (LPN) H regarding resident 104 revealed: The resident's catheter bag in a protective cover was hanging under her wheelchair. She stated the resident had the catheter put in recently after her hospitalization . -She had a general decline and was currently on hospice care. Review of resident 104's last revised 11/8/18 short term care plan revealed there was no mention of her catheter. Review of resident 104's last revised 11/28/18 long term care plan revealed no mention of her catheter. Review of resident 104's following Minimum Data Set (MDS) assessments revealed: On her 8/21/18 quarterly MDS she had not had a catheter. On her 11/14/18 significant change MDS she had a catheter. The Care Area Assessment worksheet from her 11/14/18 MDS for a catheter revealed: -Resident has an indwelling catheter. She was admitted to Hospice for Alzheimer's dementia. -The catheter should have been addressed in her care plan. Interview and record review on 12/12/18 at 1:53 p.m. with LPN H regarding resident 104 revealed: The resident had returned from the hospital on [DATE] and did not have a catheter at that time. She was readmitted to the hospital on [DATE] and returned to the facility on [DATE] without a catheter. On 11/6/18 she was admitted to hospice. On 11/7/18 a physician's telephone order was received for a catheter due to retention. -The interdisciplinary notes had not been clear on how they had obtained the [DIAGNOSES REDACTED]. The short and long-term care plans had not mentioned the catheter. Interview and record review on 12/12/18 at 2:03 p.m. with registered nurse (RN)/unit coordinator I regarding resident 104 revealed: The resident had not been urinating for long periods of time and that had been happening frequently, so she had updated hospice. Hospice then requested the catheter be put in, and a telephone order was received. She confirmed the documentation in the record had not been clear of the concern with her lack of urinating. The resident's short and long-term care plans had not been updated properly related to her catheter use. -The short-term care plans were updated by the charge nurses. -The long-term care plans were typically updated by the MDS nurses. Interview on 12/12/18 at 4:08 p.m. with RN/MDS assessment nurse [NAME] confirmed resident 104's short and long-term care plans had not been updated related to her catheter and should have been. The 11/14/18 Significant Change MDS was a comprehensive assessment that should have included overall care plan review and revisions. 3. Review of resident 19's complete medical record revealed: His care plan did not mention his chair remote not being available to him. No documentation of his chair remote control being pinned to the back of his recliner. No mention of his wife requesting him not to have his chair remote control. Refer to F604, finding 1. 4. Review of the provider's revised (MONTH) (YEAR) Care Plan, Resident-Centered Facility Standards policy revealed:The care plan is reviewed and/or revised after each assessment and PRN (as needed). The short term care plan is reviewed during this time and long term issues are carried forward to the long term care plan. *Each discipline is responsible for updated the care plan as changes occur between assessments and scheduled care conferences. Care plan changes may be made by Nurses, Social Workers, Therapy, (PT, OT, ST, PTAs and COTAs), Activity Director, Activity Coordinator (Reflections) and Activity Aides, Dietary Director and Dietary Managers .	2020-09-01
121	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	658	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to complete a comprehensive nursing assessment, document the assessment, and notify the physicians' of the findings of those assessments for two for two sampled residents (10 and 93). Findings include: 1. Review of resident 93's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Malignant neoplasm of bladder. -Retention of urine. -Other specified disorder of kidney and ureter. Review of resident 93's 11/6/18 Minimum Data Set (MDS) assessment revealed: He needed extensive physical assistance of one person in the following areas: -Personal Hygiene. -Toileting. He had an indwelling catheter. He had not had a significant weight loss or weight gain. Surveyor: Observation and interview on 12/11/18 at 4:33 p.m. with medication assistant P during resident 93's medication administration revealed:He had an indwelling catheter. The urine in his leg bag appeared to be a dark brownish-orange color. The medication assistant stated he had blood in his catheter recently. -Sometimes the resident would pull at the catheter. Staff documented the resident's urine output and the color of the urine on the report sheet for the next shift. -The nurse reviewed that report sheet every day. Surveyor: Review of the following Reflection's Unit reports for resident 93 indicated: 12/8/18 urine was dark amber during the day shift, and blood was present in his urine during the afternoon shift. 12/9/18 blood was noted in his urine on the night shift, and it was noted an amber color on the day shift. There was no urine appearance documentation of urine for the afternoon shift. 12/10/18 there was no urine appearance documentation. 12/11/18 Orange colored urine was documented on the night shift, dark red/brown color was documented on the day shift, and dark brown was documented on the afternoon shift. Interview with licensed practical nurse (LPN)/unit coordinator B on 12/12/18 at 8:10 a.m. regarding resident 93 revealed: The physician would have been contacted when there was blood noted in his urine for over twenty-four hours. -The blood was not always noted in his urine for longer than twenty-four hours. She planned to contact the physician today following due to the blood being present since 12/8/18. Surveyor: Observation, interview, and record review on 12/12/18 at 12:32 p.m. with LPN/unit coordinator B during resident 93's catheter irrigation revealed:They had an order for [REDACTED]. The resident had blood in his urine in the past. -Usually that resolved itself within twenty-four hours or so. His urine was now yellow colored. -She was aware his urine was a dark orange/brown color on 12/11/18. She confirmed a few days before that he had blood in his urine. -There had been no follow-up nursing assessments and documentation related to that in his record. 2a. Review of resident 10's interdisciplinary progress notes revealed on: 7/13/18 at 10:52 a.m. Nurses Note: Note Text: Urine obtained d/t (due to) resident does not feel well, frequent voiding with burning. 7/17/18 at 10:38 a.m. COMMUNICATION - with Family/NOK (next of kin)/POA (power of attorney). Note Text: Spoke with (son) about new orders: started on antibiotics for UTI (urinary tract infection). 7/17/18 at 10:40 a.m. Physician Visit Orders: Dr. (name) here. [MEDICATION NAME] 500mg (milligram) 1 PO (by mouth) QOD (every other day) starting tonight at 1800 (6:00 p.m.). [MEDICATION NAME] 1 gram IM (intramuscularly) today. Family notified: Spoke with son (name). There was no further documentation of any nursing assessments, interventions, vital signs, or the effectiveness of the antibiotic. b. 11/19/18 at 12:35 a.m. Resident Incident Report Date/Time of Incident: (MONTH) 19th-2017 @ 0035 (12:35 a.m.). Description of Events: Resident was found laying on the floor in her room with her head positioned right in front of the door making entry difficult. Writer squeezed through doorway to assist The Resident. Resident stated she had just finished using the bathroom and was attempted to locate a clean pad when her legs became weak and buckled. She stated that she fell to her knees, then backwards onto her bottom, then to her back. Resident denied hitting her head, but neurological observations were implemented anyway. Resident was evaluated and her only complaints were of back pain and bilateral hip pain, but stated this pain was present prior to fall. Resident assisted up and assessed for further injury with none apparent. Resident was assisted back to her bed and attempt for a cath (catheter) U/A was attempted (due to following observations: fever, back pain, lethargy, weakness, fall, and complaints of burning with urination.) Cath U/A (urinalysis) was unsuccessful due to [DIAGNOSES REDACTED]. Resident then assisted to stand to obtain clean catch U/A (due to incontinence.) Small amount of concentrated/cloudy yellow urine returned and placed in fridge to be taken to PLH (hospital) Lab (laboratory) Mental State: Normal for Resident. Alert/Oriented. Some confusion. Injury: None apparent.Vitals: T:99.8 P:69 RR:18 02:90% Room Air BP: 145/67 PERRL (pupils equal, round, and equally reactive to light), hand grasps strong bilaterally. Actions: Resident assessed, incontinence product changed, U/A obtained, and assisted back to bed. Teaching: Encouraged Resident to call for help due to weakness/lethargy. Family Notification: Will pass on to have dayshift notify family during daytime hours. 11/19/18 at 3:03 a.m. Nurses Note, Note Text: Clean-Catch U/A obtained on Resident after attempting to straight cath U/A under sterile technique with no success. Resident complains of burning with urination, back pain, weakness, lethargy, and falls. Obtained clean-catch U/A with cloudy concentrated return. Sent to first floor fridge to be taken to PLH Lab in the AM. 11/19/18 at 3:38 a.m. COMMUNICATION - with Physician Situation: FYI (for your information).Fax sent to Dr. (physician's name) notifying that U/A was obtained due to complaints of burning with urination, lethargy, weakness, fever, and back pain. Fall scene report also faxed to Dr. (physician's name) as an FYI. Background: Assessment (RN)/Appearance (LPN): Recommendations. 11/19/18 at 6:34 a.m.Nurses Note, Note Text: resident sleeping, neuros remain stable. 11/19/18 at 9:34 a.m. Nurses Note Note Text: Resident c/o some knee pain (denies that this is new or r/t (related to) the fall). Son was notified.Nurses Note Note Text: Fax sent to PCP (primary care provider) with UA results from today and med list. 11/19/18 at 5:32 p.m. Behavior Note, Note Text: When entering residents room the writer asked if she was going to go down to supper and the resident stated Well I fell this morning and I'll never be able to walk again so I'm eating in here from now on 11/19/18 at 6:14 p.m. Nurses Note, Note Text: Follow up to fall 11/19/18 0035 (12:35 a.m.). Resident remained in bed all day today, when writer asked if she was sore from her fall, she said no my legs just hurt like normal. 11/20/18 at 6:38 a.m. Nurses Note, Note Text: FOLLOW UP: neuros remain within normal limits; easily aroused, continues to feel that she can't get up and walk since 'I fell '; repositioned often, found with feet to the knees hanging out of bed x (times) 3. 11/20/18 at 11:30 a.m. Order Note, Note Text: Received fax from Dr. (physician name) with orders [MEDICATION NAME] PO BID (two times a day) x 1 week for UTI. Rx (prescription). notified. There was no further documentation of any nursing assessments regarding her fall or UTI. c. 11/25/18 at 8:55 p.m. Nurses Note, Note Text: residents blood sugar before supper was 62 gave resident a rice crispie bar and a glass of orange juice 20 minutes later blood sugar was 104 waited until after supper to administer insulin. Resident did not show signs of [DIAGNOSES REDACTED]. 11/26/18 at 8:59 a.m. Nurses Note, Note Text: Resident felt weak,and tired checked blood sugar 108 assisted to lay down. No further documentation of any more blood sugar tests and what the blood sugar was before the insulin had been administered or if it had been administrated. d. 11/13/18 at 2:36 p.m. Physician Visit Orders: Dr. (physician name) here on rounds. Orders for CBC (complete blood count) and UA (urinalysis). Family notified: Message left for (son's name). 11/15/18 at 9:24 a.m. Order Note, Note Text: Dr. (physician name) called in an order to [MEDICATION NAME] 1 PO BID x 7 days for a UTI. Repeat UA in 10 days. Rx. and son, (name) notified. Nothing had been documented on how the resident had been feeling after she had started the antibiotic for a UTI until: -11/17/18 at 7:09 a.m., 11/18/18 at 7:09 a.m., 11/19/18 at 6:39 a.m., 11/21/18 at 6:34 a.m., and 11/24/18 at 6:27 a.m. e. 11/25/18 at 10:13 p.m. Nurses Note, Note Text: No c/o (complaints of) of urinary sx.(symptoms) this evening. (R) (right) eye is slightly reddened and itchy this evening. resident c/o feels like sand in it Medicated eyes with eye drops per orders. No further documentation on her complaints of: -What her urinary symptoms were and if they had continued. -If her right eye was still red and if she still had itching and pain. f. 11/29/18 at 1:05 p.m. Nurses Note, Note Text: urine obtained for repeat per MD sent to Brown Clinic lab. 11/29/18 at 3:54 p.m. Infection Note, Note Text: Keflex started for UTI. 11/29/18 at 3:58 p.m. Order Note Note Text: Received order for Keflex 500mg. Pharmacy and (son) notified. No documentation on why the u/a had been ordered, her signs or symptoms, vital signs, and physician contact. The next nurses notes regarding any complaints or temperatures were on: -12/1/18 at 6:40 a.m.,12/2/18 at 6:57 a.m., and 12/6/18 at 6:44 a.m. g. 12/7/18 at 9:21 p.m.Nurses Note, Note Text: Resident complained of chest pain at 1945 (7:45 p.m.), resident typically has tums in her room which she can self administer but she was out, writer gave her 2 tums because she requested them. Writer checked resident's BP at the time and it was 146/70 with a pulse of 63. Writer checked back 20 mins later and resident was still having chest pain, rechecked her BP and it had gone up to 159/67 with a pulse of 80. Resident asked if she could have one of her chest pain pills. Writer did administer nitro at (YEAR) (8:15 p.m.), after about 20 mins resident stated her chest pain had gone away. Resident laying in bed now. Will continue to monitor. The next documentation was on 12/8/18 at 6:34 a.m., Nurses Note, Note Text: no c/o pain or discomfort thru the night; skin warm and dry. 3. Interview on 12/12/18 at 1:30 p.m. with the director of nursing revealed: There was no policy for documentation in the residents' records. She was aware some of the documentation had not been completed in regards to the above residents' conditions. She had discussed it in a nurse's meeting and had followed-up with some chart reviews. *She had not documented those chart reviews and did not say when they had been completed.	2020-09-01
122	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	686	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure three of eight sampled residents (29, 91, and 114) had the appropriate interventions in place and were repositioned to prevent pressure injuries from developing. Findings include: 1. Review of resident 29's medical record revealed: She had been admitted on [DATE]. Her [DIAGNOSES REDACTED]. She had a history of [REDACTED]. -Her current weight was one hundred and fifteen pounds. She had been dependent upon the staff: -To anticipate and assist her with all activities of daily living (ADL). -To develop and implement interventions for her to ensure pressure injuries had not occurred. Further review of resident 29's medical record revealed: She was alert with impaired cognitive capabilities due to her dementia. On 12/3/18 the staff identified a stage 2 pressure injury to her right inner buttock. -That pressure injury had been an intact fluid filled blister. On 12/5/18 a weekly wound assessment had been completed. -The staff had been directed to apply [MEDICATION NAME] barrier cream to that pressure injury. -A fax had been sent to the physician regarding the stage 2 pressure injury. -The son had been notified. No documentation to support: -The physician had responded or recommended a different type of treatment. -The wound had been healed as of 12/12/18. Review of resident 29's short-term care plan from 1/30/18 through 12/11/18 revealed: On 12/5/18 staff had documented: 0.7 x 0.4 cm (centimeters) clear, fluid filled blister (intact) to R (right) mid-inner buttock. -That documentation had occurred two days after the initial identification of the wound on 12/3/18. No further documentation to support: -What interventions were put in place for the staff to follow to promote healing of that wound. -If the physician and responsible party had been notified. -What specific treatment, if any, had been ordered to promote healing. -When or if the wound had healed. Review of resident 29's 11/28/18 comprehensive care plan revealed: She had been at high risk for skin breakdown. Confirmed she required all the pressure relieving devices observed above. She should have been turned/repositioned per the Care Plan Standard. -No documentation to support what that Care Plan Standard consisted of. Random observations on 12/10/18 from 5:30 p.m. through 6:10 p.m. of resident 29 revealed: She was sitting in a reclining wheelchair (w/c) in the dining room. She had: -A pressure relieving cushion in the seat of her w/c. -Severe contractures to her neck and right hand. -Been unable to make spontaneous and random movements of her neck, arms, and legs without staff support. -Required the staff to assist her with eating. Random observations on 12/11/18 from 7:30 a.m. through 11:30 a.m. of resident 29 revealed: She had been: -In the dining room receiving assistance with her meals or in the sitting area by the nurses' station. -In her w/c during all observations. No observations of the staff attempting to reposition her to relieve pressure off of her bottom. Interview on 12/11/18 at 7:30 a.m. and again at 9:45 a.m. with certified nursing assistant (CNA) T regarding resident 29 revealed: At 7:30 a.m. the surveyor had requested to observe the resident with transfers and personal care that morning after breakfast. She stated the resident was up for the morning and would not be laid down to rest or assisted until after lunch time. At 9:45 a.m. the surveyor again requested to observe any and all personal care with the resident. The CNA again stated the resident was up for the morning until after lunch time. Observation on 12/11/18 at 4:12 p.m. of resident 29 revealed she had been sitting in her w/c and was located in the sitting area by the nurses' station. Interview on 12/11/18 at 4:24 p.m. with nurse aide in training (NAT) Z regarding resident 29 revealed she: Had only worked on the floor the resident resided. Knew the resident well and her routine. Stated: -She is already up for the afternoon. -I get here around 3:00 p.m., and the resident is usually up for the afternoon. -We won't have to assist before supper. -The earliest we will do anything for her will be when we lay her down after supper around 6:30 p.m. Had not been aware the resident had an area of concern on her right buttock. Agreed she should have been informed about the wound to her bottom. Interview on 12/11/18 at 4:30 p.m. with licensed practical nurse (LPN) Y regarding resident 29 revealed he: Confirmed the resident had been at high risk for skin breakdown and was dependent upon the staff to assist her with all ADLs. Stated: -She gets up early between 6:00 a.m. and 6:30 a.m. -I get here at 6:00 a.m., and she is usually up. Had not been aware of a pressure injury to the resident's bottom. Could not locate documentation to support the treatment the wound had required or if it had been healed. Agreed the charge nurse and direct care givers should have been informed of the pressure injury to ensure proper care was provided. Was not aware the staff were not repositioning her or off-loading her bottom after she was up in the w/c. Stated That is too long for her to be sitting without some type of repositioning. Review of resident 29's (MONTH) (YEAR) medication and treatment administration record (MAR/TAR) revealed: On 9/20/18 the staff were to have applied [MEDICATION NAME] to her right upper buttock every shift for redness. No documentation to support: -The staff were to monitor an area of concern on her right buttock. -A treatment specific for the stage 2 pressure injury located on her right buttock. Review of resident 29's progress notes from 12/1/18 through 12/12/18 revealed: On 12/3/18: -Res (resident) entire R buttock is reddened, but does blanch. -Res also has pea sized blister to R inner buttock, area not open and no s/s (signs and symptoms) of infection noted. -AV ([MEDICATION NAME]) applied to area. No documentation regarding the pressure injury after 12/3/18. Observation and interview on 12/12/18 at 8:30 a.m. of CNA V with resident 29 revealed she: Had assisted the resident to lay down and check her incontinent brief after breakfast. Was aware of the stage 2 pressure injury located on her right buttock. Confirmed: -The charge nurse was made aware of any skin concerns for the residents. -The stage 2 pressure injury was no longer there. Stated: -I worked on Monday, and it was no longer there. -We typically are supposed to do a check/change on her in the morning, and then get her back up depending on the activity. 2. Review of resident 114's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED]. His 8/23/18 Admission Referral/Baseline Care Plan information indicated he: -Had weakness due to [MEDICAL CONDITION] with a left hip contusion from a fall. -Had pain in his back and left hip. -Had required the use of a catheter. -There had been no documentation to support he: --Was at high risk for skin breakdown. --Required pressure relieving devices or assistance with repositioning. He had been dependent upon the staff: -To assist him with all of his ADLs. -To develop and implement interventions for him to ensure pressure injuries had not occurred. His memory recall had been moderately impaired. On 9/9/18 the staff identified a stage 2 pressure injury to his right inner buttock. -That pressure injury had been an intact fluid filled blister and was identified eighteen days after his admission. On 9/27/18 the stage 2 pressure injury had been healed. Review of resident 114's short-term care plan from 8/23/18 through 12/05/18 revealed: On 9/9/18 staff had documented: Stage II (2) pressure injury to R inner buttock. No documentation to support: -What interventions were put in place for the staff to follow to promote healing of that wound. -What specific treatment, if any, had been ordered to promote healing until 9/13/18. Review of resident 114's 9/13/18 comprehensive care plan revealed he: Had a focus area that identified him at a high risk for skin breakdown d/t (due to) decreased mobility. Required the use of: -A pressure reducing cushion in his w/c. -An alternating pressure pad to prevent skin breakdown. The focus area with the above interventions had not been initiated until 9/13/18. -That had been four days after an area of concern had been identified to his right buttock. Had no documentation to support the amount of assistance he required from the staff for repositioning him. Observation on 12/10/18 at 4:47 p.m. of resident 114 revealed: He had been in his room sitting in a rocking w/c. An alternating pressure pad on top of his mattress. A pressure relieving cushion on the seat of his w/c. He had a recliner in his room with no pressure relieving device on it. His wife had been there visiting with him. He had been visibly shaking. They had been waiting for the nurse to come in and assess him. Interview on 12/11/18 at 11:14 a.m. with resident 114's wife revealed: He required the use of a pressure relieving cushion in his w/c. She stated: His bottom is red so he needs that. -She was not aware of one being placed in his recliner when he sat in it. Random observations on 12/11/18 from 7:30 a.m. through 11:30 a.m. of resident 114 revealed: He had been: -In the dining room eating his meals or in the sitting area by the nurses' station. -In his w/c during all observations. No observations of the staff attempting to reposition him to relieve pressure off his bottom. Interview on 12/11/18 at 7:30 a.m. and again at 9:45 a.m. with certified nursing assistant (CNA) T regarding resident 114 revealed: At 7:30 a.m. the surveyor had requested to observe the resident with transfers and personal care that morning after breakfast. CNA T stated the resident was up for the morning and would not be laid down to rest or assisted unless he asked. At 9:45 a.m. the surveyor again requested to observe any and all personal care with the resident. The CNA again stated the resident was up for the morning and would only be assisted if he requested to go to the bathroom or sit in his recliner. Interview on 12/11/18 at 1:25 p.m. with CNA T regarding resident 114 revealed his wife was here; and they were at an activity. Interview on 12/11/18 at 4:26 p.m. with nurse aide in training (NAT) Z regarding resident 114 revealed she: Stated: -He is already up for the afternoon. -I get here around 3:00 p.m., and the resident is usually up for the afternoon. -We won't have to assist him before supper unless he specifically asks. -The earliest we will do anything for him will be when we lay him down after supper sometime. Interview on 12/11/18 at 4:35 p.m. with licensed practical nurse (LPN) Y regarding resident 114 revealed he: Confirmed the resident had been at high risk for skin breakdown and was dependent upon the staff to assist him with all ADLs. Stated: -He gets up early between 6:00 a.m. and 6:30 a.m. -I get here at 6:00 a.m., and he is usually up. Had been aware of a pressure injury to the resident's bottom. Was not aware the staff were not repositioning him or off-loading his bottom after he was up in the w/c unless he requested to go to the bathroom or be moved. Stated: -That is too long for him to be sitting without some type of repositioning. -We try to move them as much as possible. Agreed the focus area and interventions on the care plan for the resident had been reactive versus proactive. 3. Interview on 12/12/18 at 10:14 a.m. with CNA T regarding the above care plans revealed: She confirmed they used the comprehensive care plans located in the computer system. They would have repositioned residents according to the Care Plan Standard. -That consisted of just the moving of a resident when they were in a chair or laying in bed. She stated: Like moving from side-to-side if they stay in bed. If a resident was to have been repositioned every two hours or more it would have been specified on their care plan. Interview on 12/12/18 at 2:15 p.m. with registered nurse (RN)/Minimum Data Set (MDS) assessment coordinator (E) and RN/wound nurse (O) regarding residents 29 and 114 revealed they: Agreed both of the residents had been dependent upon the staff to: -Assist them with all their ADLs. -Develop and implement interventions for them to ensure pressure injuries had not occurred. Had not been aware of all the areas of concern identified above with: -Repositioning to ensure skin breakdown had not occurred. -No documentation to support: --Physician awareness, repositioning expectations for residents at high risk, timeliness of treatments, high risk concerns upon admission, and interventions. Agreed resident 114's care plan and focus area and interventions to prevent skin breakdown had been reactive versus proactive. Confirmed the Care Plan Standard for repositioning would have occurred every two to three hours. -Someone at high risk for skin breakdown should have been repositioned every two hours or more. -The care plans should have been more specific to those resident's repositioning needs. The entire interdisciplinary care team (IDT) would have been responsible for the reviewing and updating of the resident's care plan. -Confirmed the direct care givers would have used that care plan to ensure interventions were completed and put in place. Interview on 12/12/18 at 2:45 p.m. with the director of nursing revealed she: Had not been aware of all the concerns with repositioning and documentation identified above for residents 29 and 114. Confirmed and supported the interview above with the MDS assessment coordinator and wound nurse. 3. Review of resident 91's medical record revealed: She had been admitted on [DATE]. Her [DIAGNOSES REDACTED]. She required assistance with of all her ADLs. Her current weight was around eighty pounds. She had a previous pressure injury to her coccyx area that had healed on 10/18/18. -That area had re-opened on 12/2/18. Observation and interview on 12/10/18 at 4:05 p.m. with LPN H regarding resident 91 revealed:The resident was sitting in her w/c in the lounge area. She had: -A pressure relieving cushion in the seat of her w/c. -An air mattress on her bed. -A specialty cushion to raise her heels up when she was in bed. LPN H stated the resident currently had a stage two pressure injury to her coccyx area. -It was covered with a [MEDICATION NAME] dressing. The dressing was not changed every day. -It was changed on Fridays and as needed. A specific nurse did the weekly wound assessments. The charge nurses did the daily wound treatments as ordered. The current coccyx pressure injury recently re-opened from a previously healed area. The resident was very small and frail. Observation and interview on 12/11/18 from 8:54 a.m. through 9:04 a.m. with CNA J during resident 91's personal care revealed:She had a current pressure injury to her coccyx area. An intact dressing was in place to her coccyx area, and it was dated 12/11/18. She appeared bony with fragile skin. -No other pressure injuries were observed, but there were areas of scarring on her skin. She stated the nurses did the treatment to the area. The CNAs applied a barrier cream around the dressing when they performed incontinence care. She required: -A total mechanical lift to be moved from her w/c to the bed. -Total assistance of one staff person for her ADLs. The staff usually only got her up for meals. -She would stay in bed most of the rest of the time. They positioned her on her sides instead of her back. Interview and record review on 12/12/18 at 9:32 a.m. with LPN H regarding resident 91 revealed:The resident was very thin and had fragile skin. She spent most of her time in bed due to her high risk for further skin breakdown. She had a history of [REDACTED]. According to the Skin Observation Tools by the nurses on the following dates she: -Had no pressure injuries on 11/6/18. -Had two pressure injuries on 12/2/18. --One stage two area on her right buttock. --One stage two area on her sacrum. The Skin Observation Tools were done by the charge nurse. The 12/3/18 Wound Documentation sheet and Wound -Weekly Observation tools from the wound nurse indicated she had only one stage two facility-acquired pressure injury on her coccyx. -There was no mention of the right buttock or sacrum areas from 12/2/18. -The treatment was to use [MEDICATION NAME] barrier cream every shift. --There was no mention of a [MEDICATION NAME] dressing. A 12/4/18 nurse's note indicated the resident's daughter was updated on a spot on her left buttock. LPN H stated they had been using the [MEDICATION NAME] dressing to the coccyx area for protection for months. -That was also the current treatment. She thought the coccyx area was the same as the sacrum area that was mentioned on 12/2/18. -There was no pressure injury to the right or left buttock currently. She was unsure why: -The two areas from 12/2/18 were not mentioned on the 12/3/18 assessment. -The 12/4/18 note of a left buttock spot was not mentioned anywhere else. -If the notes had discrepancies there should have been clarification and appropriate documentation. The wound nurse had completed the 12/3/18 assessments, and the 12/2/18 and 12/4/18 notes had been done by charge nurses. Interview on 12/12/18 at 9:55 a.m. with CNAs J and M regarding resident 91 revealed: They were only aware of the resident having one pressure injury to her coccyx area. The CNAs applied [MEDICATION NAME] barrier cream around her dressing site every shift. The nurse took care of the dressing. Further interview, record review, and observation on 12/12/18 at 9:57 a.m. with LPN H of resident 91 and her medical record revealed:She confirmed there had been only one weekly wound assessment completed. -That wound assessment was on 12/3/18. -There should have been another weekly wound assessment done on 12/10/18. She thought the wound nurse did those weekly assessments. After removal of the 12/11/18 [MEDICATION NAME] dressing only one pressure injury was visible on the resident's coccyx area. -There were no other pressure injuries seen. She stated they would put a new [MEDICATION NAME] dressing over the area and apply the [MEDICATION NAME] cream around that dressing site. Interview and record review on 12/12/18 at 10:12 a.m. with RN O regarding resident 91 revealed:She did the initial wound assessments for the pressure injuries. -The assistant director of nursing (ADON) usually did the weekly assessments after the initial assessment was completed. -She would have helped do those weekly assessments if the ADON was unavailable. She had done the resident's initial wound assessment on 12/3/18 after hearing about the 12/2/18 pressure injuries. -When she had assessed the resident she only found one pressure injury on her coccyx. -She thought the sacrum pressure injury was most likely the same area she had documented as the resident's coccyx. -There was no pressure injury on the resident's right or left buttock. She should have put a note in the initial assessment or the nurses progress notes to clarify the discrepancies from the 12/2/18 assessment to her 12/3/18 assessment. She stated the weekly assessment should have been done by 12/10/18. The ADON usually did her weekly assessments on Thursdays. -She must not have done the 12/6/18 assessment the week before, since it had just been assessed on 12/3/18. -It would be getting re-assessed on 12/13/18 that was actually ten days later. She was not aware the nurses were not applying the [MEDICATION NAME] cream to the actual pressure injury. -The [MEDICATION NAME] dressing should have been discontinued, and the cream should have been applied to the pressure injury and surrounding area by the nurses every shift. She had implemented the [MEDICATION NAME] as a new treatment on 12/3/18, but she had not realized they had kept using the [MEDICATION NAME] dressing. Interview and record review on 12/12/18 at 10:42 a.m. with the ADON regarding resident 91 revealed: The resident had a history of [REDACTED]. She did the weekly wound assessments on Thursdays every week after RN O did the initial assessment. She had not done the resident's weekly assessment on 12/6/18, since it had just been done on 12/3/18. -She planned to assess it on 12/13/18. She agreed when it was not assessed for ten days that would not have been considered weekly. She confirmed there was conflicting documentation related to her pressure injury. -The notes should have clarified where the actual injury was and been documented appropriately. If the nurses were not applying the [MEDICATION NAME] to the coccyx injury and had continued the [MEDICATION NAME] then the new treatment was not being followed. -The [MEDICATION NAME] should have been discontinued when the new treatment was started. Review of the provider's revised (MONTH) (YEAR) Pressure Ulcer policy and procedure revealed:Residents with pressure ulcer(s) will be evaluated by RNs/LPNs on a weekly basis by measuring consistently and accurately throughout the facility. Treatment will be provided per JLC (Jenkins Living Center) wound care protocol or as ordered by physician to promote healing.The nurse who initially discovered the wound was responsible to 8. Implement pressure relieving measures not already in place .) Pressure relieving measures could have included:-Air mattress. -Gel cushion in wheelchair and recliner. -Repositioning.	2020-09-01
123	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	692	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure one of three sampled residents (93) received adequate hydration. Findings include: 1. Review of resident 93's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Muscle weakness. -Hypoxemia. -Malignant neoplasm of bladder. -Retention of urine. -Other specified disorder of kidney and ureter. -Unspecified [MEDICATION NAME] degeneration. -[MEDICAL CONDITION] without behavioral disturbances. Review of resident 93's 11/6/18 Minimum Data Set (MDS) assessment revealed: He had clear speech. His vision was highly impaired. He needed extensive physical assistance of one person for the following areas: -Bed mobility. -Transfer. -Walking in room. -Locomotion on unit. -Dressing. -Personal Hygiene. -Toileting. -Eating. He had an indwelling catheter. He had not had a significant weight loss or weight gain. Random observations from 12/10/18 through 12/12/18 at the following times of resident 93 revealed: 12/10/18 at 4:10 p.m. he was sitting in his recliner with music on and the water pitcher was across the room not, within his reach. 12/11/18 at 7:45 a.m. he was in his recliner with no music on and the water pitcher was across the room not, within his reach. 12/11/18 at 3:17 p.m. he was in the dining room for an activity with no fluids offered or within his reach. 12/12/18 at 8:29 a.m. he was sitting in the recliner and the water pitcher was not within his reach. -His lips appeared dried and chapped. -There was a loose piece of skin on his lower lip on the left side, near the corner of his mouth. 12/12/18 at 9:25 a.m. he was at an activity in the lounge and was offered a six ounce (oz) glass of juice. He drank it very quickly and was not offered more. 12/12/18 at 10:38 a.m. he was in his room sitting in his recliner with his eyes closed and the water pitcher was on the bedside table across the room. 12/12/18 at 12:32 p.m. licensed practical nurse (LPN) B/unit coordinator flushed his catheter and had not offered fluids. Interview on 12/12/18 at 8:10 a.m. at 1:23 p.m. with LPN B/unit coordinator regarding resident 93 revealed: Intake was not monitored due to not having orders to monitor it. Output was monitored due to him having the indwelling catheter. He was at risk of dehydration. He never drank the water in his room nor had he attempted to drink it. He drank all offered fluids at meal times. Fluids were offered to him at the morning activity. Fluids were offered to him at snack times, once in the afternoon, and once in the evening. Interview on 12/12/18 at 3:05 p.m. with the director of nursing (DON) regarding resident hydration revealed: She expected fluids to be offered to residents at meals, between meals and when providing care. Certified nursing assistants (CNA) would notify a nurse when there was a change in a resident's baseline for hydration. Review of Resident 93's Nutritional Assessment from 11/5/18 revealed: The registered dietician (RD) had recommended: -2000 cubic centimeters (cc) of fluid per day. -He needed assistance with meals. -Fluids were to be encouraged. Review of Resident 93's limited, documented intake between 11/7/18 through 12/12/18 revealed: His fluid intake for 11/7/18 was 1,020 cc. His fluid intake for 11/14/18 was 840 cc. His fluid intake for 11/21/18 was 600 cc. His fluid intake for 11/28/18 was 1,200 cc. His fluid intake for 12/12/18 through lunch time was 720 cc. He often refused fluids at meal times. There was no other documentation regarding his fluid intake during the above time frame. Review of Resident 93's documentation regarding output from 11/27/18 through 12/12/18 revealed: Outputs as low was 50 cc in an eight hour period. Outputs as low as 500 cc in a twenty four hour period. On 12/8/18 it is noted that he had blood in his urine. *From 12/8/18 through 12/11/18 he is noted to have dark amber urine.	2020-09-01
124	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	697	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to implement an individualized and consistent process to assess, manage, and follow-up on pain for one of four sampled residents (114) who had high pain levels. Findings include: 1. Review of resident 114's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED]. His 8/23/18 Admission Referral/Baseline Care Plan information indicated: -He had weakness due to [MEDICAL CONDITION] with a left hip contusion from a fall. -He had pain in his back and left hip. --There was no documentation on what was used to help control his pain. On 8/23/18 the physician had ordered: -Tylenol extended release (ER) 650 milligram (mg) one tablet once a day for pain. -Tylenol ER 650 mg two tablets twice a day for pain. On 9/5/18 the physician had ordered Tylenol 325 mg two tablets every six hours as needed (PRN) for pain. He had been dependent upon the staff to assist him with all of his activities of daily living. His memory recall had been moderately impaired. Observation on 12/10/18 at 4:47 p.m. of resident 114 revealed: He had been in his room sitting in a rocking wheelchair (w/c). His wife had been there visiting with him. He had been visibly shaking. They had been waiting for the nurse to come in and assess him. Interview on 12/11/18 at 11:14 a.m. with resident 114's wife revealed: She confirmed he had arthritis in his back and that had caused him pain. She stated: -I think they are trying to manage, it but I'm just not sure that they really are. -Last night he was shaking terribly, and no one knew why. -They stopped a med (medication) the doctor had recently started him on. -He's very sleepy today. Review of resident 114's 8/23/18 Admission Physical Nursing assessing revealed he had arthritic joint pain. At the time of the assessment he had not shown any signs of pain. Review of resident 114's 8/30/18 Admission Minimum Data Set (MDS) assessment indicated: He had: -Scheduled pain medications but had not received any PRN pain medications. -No non-medication interventions for pain. -Pain almost constantly that had made it hard for him to sleep at night and limited his day-to-day activities. His pain intensity had been severe. His 8/30/18 Care Area Assessment (CAA) worksheet related to pain on the above MDS stated: -Resident states that he has arthritis pain 'all over.' -He states his pain is almost constant and he rates his pain as 'severe.' -He takes schedule Tylenol for his pain and voiced he was satisfied with Tylenol. Continued review of resident 114's MDS assessments indicated on 11/20/18 he: Continued to have scheduled pain medications. Had required the use of PRN pain medications during the assessment window. Continued to have no non-medication interventions. Continued to have pain almost constantly. Had rated his pain as a ten on a scale of zero to ten with zero the least and ten the most pain. Review of resident 114's Pain Interview assessments revealed: On 8/28/18 he had: -Experienced severe pain almost constantly within the last five days. --That pain had made it hard for him to sleep at night and interfered with his day-to-day activities. -Been on a scheduled pain reliever with no PRN medications provided. -Not required any non-medication interventions to assist him with pain control. -Not been assessed for the frequency of his pain. -The following comment documented: Resident was confused, and was easily distracted. He did respond when asked again, he stated that his current pain medication helped his pain, and he agreed that he was satisfied with it. -No referral made to the physician to ensure his pain control was managed appropriately. On 9/30/18 he had: -Continued to experience constant and severe pain. -Denied that his pain interfered with his sleep and day-to-day activities. -Not been assessed for the frequency of his pain. -Continued on the same pain medication with no PRN medications provided. -Required the use of a non-medication intervention for his pain. --That intervention had been a topical pain medication ointment. -The following documentation: Resident stated that the blue emu helped his lower back more than anything. He asked staff to put some on for him, which I did. Resident is confused, he stated I'm 61 and my wife is 2 years younger. Resident's birthday is in 1937. -No referral made to the physician to ensure his pain control was managed appropriately. On 11/19/18 he had: -Continued to experience constant and severe pain. -Rated his pain as a ten on a scale of zero to ten. -Continued on the same pain medication with PRN medications provided for further control. -Not required the use of any non-medication interventions to assist with his pain control. -The following documentation: Pain to legs fax sent to PCP (primary care provider) regarding pain level. Review of resident 114's 9/12/18 comprehensive care plan revealed: A focus area; (Resident's name) is on pain medication therapy r/t (related to) his dx (diagnosis) of chronic pain as he has arthritis. -That focus area had been reviewed and revised on 11/28/18. A goal for that focus area: (Resident name) will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions for that focus area: -Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every)-shift. -Review every shift for pain medication efficacy. Assess whether pain intensity acceptable to resident, no treatment regiment or change in regimen required but continue to monitor closely. -Controlled when therapeutic regimen followed, but not always followed as ordered. -Therapeutic regimen followed, but pain control not adequate, changes required. -Had been initiated on 9/13/18 with no revision made past that date. Review of resident 114's physician's progress notes revealed: On 10/03/18 the physician documented: -The patient (resident) was seen at (facility name) for a follow up on his knee pain. The patient seems to be very confused and he had several different issues. He did not really seem to have a clear idea who I was. His wife is still checking him on a regular basis. she and staff have not noticed any new problems. -No change in medications needed. -His leg pain seems to be [MEDICAL CONDITION] related. On 11/21/18 the physician documented: -The patient remains very confused. -He does not appear to be in any distress. -Nurses report knee pain, but that seems to be quite variable. --That report and documentation had occurred the next day after his 11/20/18 pain assessment interview. -No change in medications needed. -His leg pain seems to be [MEDICAL CONDITION] related. On 12/5/18 the physician documented: -The patient is really not communicating very well anymore. -He just seems to be so confused that he cannot really get any thoughts across. -The staff has noticed that he still seems to have a lot of knee pain and leg pain and they were wondering if we could try anything else to help out. -I do not really want to try any strong narcotics because I am afraid it will make his confusion worse. -His pain is not under the best control. I think we will try some low dose [MEDICATION NAME] and see if he tolerates that adequately. --The progress note was completed and signed by the physician on 12/15/18. --That had been three days after the surveyors had completed their review of the facility and left. Continued medical record review for resident 114 revealed no documentation to support a change had been made to his therapeutic regimen until 12/5/18. The physician had ordered [MEDICATION NAME] 100 mg three times a day (TID). That medication had been discontinued on 12/14/18 d/t (due to) possible adverse side effects. There had been no further changes made to his therapeutic regimen to ensure adequate pain control had been achieved. Review of resident 114's (MONTH) (YEAR) through (MONTH) (YEAR) medication and treatment administration records (MAR/TAR) revealed: On 8/23/18 he was to have his pain level assessed every shift for eight days. -His pain level had been consistently documented at zero. -There was no mention of using a non-verbal or alternate pain scale or assessment during times of increased confusion. -His pain level was no longer assessed every shift after the eight days had been completed. From 9/1/18 through 12/12/18 he had received PRN Tylenol for complaints of pain once a day for a total of nine days. -His pain level varied from zero to eight with effective pain control obtained. There was no documentation to support he had required the use of a PRN medication from 8/23/18 through 8/31/18. He could have had three different types of medicated ointment applied to his painful joints PRN. -The Blue-Emu Super Strength cream had only been applied once for join pain during the above time frame. -No documentation to support the other types of medicated ointment had been used to help with pain relief. Observation on 12/12/18 at 10:25 a.m. of certified nursing assistant (CNA) T with resident 114 revealed: The resident had been in his room sitting in a rocking w/c. -He had been moaning, restless, confused, and looking for his wife. The CNA prepared to transfer him into his recliner. He had required the use of an EZ stand mechanical lift for transfers. He had moaned on and off during the transfer from his w/c to the recliner. He continued to moan after being settled into the recliner. Interview on 12/12/18 with resident 114 at the time of the above observation revealed he: Confirmed he was having pain. Stated: -I always have pain.-Its constant. -I'll be fine its nothing new. Interview on 12/12/18 with CNA T at the time of the above observation and interview with resident 114 revealed: She confirmed he: -Had complaints and signs of pain. -Had pain frequently and on a daily basis. -Complained of pain in his legs and back. She stated: -I usually tell the nurse about his pain. -They know about his pain. -I think he gets meds for it, and she just gave him his meds, I think it was for pain. Interview on 12/12/18 at 1:50 p.m. with Minimum Data Set (MDS) assessment coordinators [NAME] and K regarding resident 114 revealed they: Confirmed the resident had chronic pain related to his arthritis. Had not been aware of all the concerns identified above regarding the resident's uncontrolled pain. Would have completed a pain assessment and interview with each MDS assessment. They would not have observed the resident with transfers or with direct care being provided to support their quarterly and non-comprehensive MDS reviews. MDS coordinator K had completed the resident's 11/20/18 quarterly MDS and had been aware of his pain concerns. -She had faxed the physician regarding his pain concerns and verbally informed the nurse of her assessment and the fax she had sent. -She would not have followed-up on those concerns. Confirmed there was no non-medication interventions listed on his care plan, and there should have been. Agreed there was no consistent process for the nurses to assess, document, and follow through to ensure the resident's pain control had been managed appropriately. Interview on 12/12/18 at 2:40 p.m. with the director of nursing (DON) regarding resident 114 revealed she: Had not been aware of all the concerns identified above regarding the resident's pain and the need for better control. Did not have a policy or procedure in place for the staff to follow to ensure all residents pain had been managed and controlled in an appropriate manner. Agreed a better pain management process should have been developed to ensure adequate pain control for him had occurred. Review of Potter and Perry's 2013 Ninth Edition; Fundamentals of Nursing: Chapter 44; page 1,022; on Pain Management, revealed: Knowledge of pain physiology and the many factors that influence pain help you manage a patient's (resident) pain. Critical thinking attitudes and intellectual standards ensure the aggressive assessment, creative planning, and thorough evaluation needed to obtain an acceptable level of patient pain relief while balancing treatment benefits with treatment-associated risks. Successful pain management does not necessarily mean pain elimination but rather attainment of mutually agreed-on-pain relief goal that allow patients to control their pain instead of the pain controlling them. Nurses approach pain management systemically to understand and treat a patients pain. The American Nurses Association (ANA, 2005) upholds that pain assessment with it is within the scope of every nurse's practice. Review of Potter and Perry's 2013 Ninth Edition; Fundamentals of Nursing: Chapter 44, page 1,023, on Pain Management revealed: *Routine Clinical Approach to Pain Assessment and Management: ABCDE: -A: Ask about pain regularly. Assess pain systematically. -B: Believe patient and family in their report of pain and what relieves it. -C: Choose pain control options appropriate for the patient, family, and setting. -D: Deliver interventions in a timely, logical, and coordinated fashion. -E: Empower patients and their families. Enable them to control their course to the greatest extent possible.	2020-09-01
125	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	698	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, policy review, and outpatient services agreement review, the provider failed to follow professional standards for one of one sampled resident (112) who received [MEDICAL TREATMENT] treatments at an off-site facility including: Consistent assessments of the resident before and after [MEDICAL TREATMENT] treatments. Monitoring of the resident's [MEDICAL TREATMENT] shunt according to facility policy. Findings include: 1. Review of resident 112's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. He went to [MEDICAL TREATMENT] three times a week at an outpatient facility. Observation and interview on 12/10/18 at 4:29 p.m. with resident 112 revealed he: Went to [MEDICAL TREATMENT] three times a week at an outpatient facility. Had a pressure-type dressing in place to his left forearm shunt site. Stated he had [MEDICAL TREATMENT] earlier that day and would take the dressing off by himself later. Indicated the nurses did not do anything with his shunt site. Interview on 12/11/18 at 10:35 a.m. with licensed practical nurse (LPN) C regarding resident 112 revealed:He confirmed the resident went to [MEDICAL TREATMENT] every week on Monday, Wednesday, and Friday. He was independent and did most things himself. Review of resident 112's revised 11/29/18 care plan revealed:A focus area for .[MEDICAL TREATMENT] 3 times a week r/t (related to) [MEDICAL CONDITION]. -Interventions were: --Do not draw blood or take B/P (blood pressure) in Left arm with Shunt. --Encourage resident to go for the scheduled [MEDICAL TREATMENT] appointments. Resident receives [MEDICAL TREATMENT] 3 times a week.A focus area of .at risk for shortness of breath, chest pains, [MEDICAL CONDITION], high blood pressure, infected access site, itchy skin, nausea, and vomiting d/t (due to) [MEDICAL TREATMENT] and abnormal blood sugar d/t diabetes.-Interventions included: --(Name) goes to Kidney [MEDICAL TREATMENT] 3x per week for [MEDICAL CONDITION]. Be aware he is tired afterwards. Nursing to monitor his shunt site to his left forearm daily for redness or pain. report to his dr if he has either. Do not take his blood pressure from his left arm.--Monitor his feet and hands for [MEDICAL CONDITION]. A focus area of (Name) is independent with all aspects of his day-to-day activities except for needing staff assist with eating and bathing. Interview on 12/12/18 at 3:23 p.m. with LPN D regarding resident 112 revealed:There were no specific nursing assessments related to [MEDICAL TREATMENT] or his shunt site. If there was a concern the nurse would have assessed and follow-up on that. [MEDICAL TREATMENT] put pressure dressings on his shunt site, and he usually took those off himself. There was no documentation from the nurses related to checking his shunt site or specific assessments related to [MEDICAL TREATMENT]. Interview on 12/12/18 at 3:52 p.m. with the assistant director of nursing confirmed the above findings. There was no documentation to support the nurses had been assessing his shunt site or condition related to [MEDICAL TREATMENT]. The policy indicated shunts should have been checked daily and as needed. Interview on 12/12/18 at 3:58 p.m. with registered nurse [NAME] regarding resident 112 revealed:She was one of the Minimum Data Set assessment coordinators. She confirmed there was no documentation to support the nurses had assessed his condition related to [MEDICAL TREATMENT] or had been checking his shunt site. His care plan and the provider's policy had not been followed to check his shunt site daily. Review of the provider's revised (MONTH) 2014 [MEDICAL TREATMENT] Residents, Care Measures policy revealed:1. Any signs or symptoms of infection (redness, swelling, pain or drainage) at shunt site or elsewhere will be immediately reported to physician and/or [MEDICAL TREATMENT] staff. 2. Thrill and bruit (shunt assessments) will be checked QD (every day) and PRN (as needed). Review of the provider's effective (MONTH) 2003 [MEDICAL TREATMENT] Services Agreement revealed: The provider would perform its services in accordance with accepted professional standards of practice. The provider and the [MEDICAL TREATMENT] provider would each prepare and maintain complete and detailed clinical records concerning facility residents receiving services. Each clinical record shall completely, timely, and accurately document all services provided to, and events concerning, each patient (resident) including evaluations, treatments, and progress notes collectively, and will remain confidential.	2020-09-01
126	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	842	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure complete and accurate documentation was in the medical record for 8 of 29 sampled residents (10, 19, 29, 91, 93, 104, 112, and 114). Findings include: 1a. Resident 114's medical record had incomplete documentation to support concerns of his need for better pain control. Refer to F697, finding 1. b. Resident 114's medical record had incomplete documentation regarding his pressure injury he had acquired while receiving care and services from the provider. Refer to F686, finding 2. 2. Resident 29's medical record had incomplete documentation regarding her pressure injury she had acquired while receiving care and services from the provider. Refer to F686, finding 1. 3. Resident 10's medical record had incomplete documentation of concerns for urinary tract infections, blood sugars, a fall, and chest pain. Refer to F658, finding 2. 4. Resident 104's medical record had incomplete documentation of concerns with her urination and the need for a catheter. Refer to F657, finding 2. 5. Resident 112's medical record had incomplete documentation to support assessments of his [MEDICAL TREATMENT] shunt and condition. Refer to F698, finding 1. 6. Resident 91's medical record had incomplete and inaccurate documentation regarding her pressure injury. Refer to F686, finding 3. 7. Review of resident 93's medical record revleaed there was no nursing documentaiton regarding fluid intake for him. The dietary department had only documented fluid intake one time per week. Refer to F692, finding 1. Interview on 12/12/18 at 3:05 p.m. with director of nursing revealed there was no policy for documentation. 8. Review of resident 19's medical record revealed there was no nursing documentation or care planning regarding his wife requesting to put his feet up and she did not want him to have access to his recliner remote control. Refer to F604, finding 1. Surveyor: 9. Interview on 12/12/18 at 3:11 p.m. with the director of nursing revealed there was no policy or procedure in place for the staff to follow to ensure complete and accurate documentation had occurred for the residents' medical records.	2020-09-01
127	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	880	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure: Two of two dietary aides (R and S) washed their hands and used gloves appropriately during two of two (supper and breakfast) meals observed in the third floor assisted dining room. One of one licensed practical nurse (LPN) (F) used proper technique during a dressing change for one of one sampled resident (139). One of one certified nursing assistant (CNA) (U) washed her hands and used gloves appropriately during catheter care for one of one sampled resident (73). Two of two CNAs (W and X) washed their hands and used gloves appropriately during personal care for two of two sampled residents (60 and 103). One of one LPN (Q) used proper handwashing techniques during medication administration for three of three randomly observed residents (3, 48, and 74). Findings include: 1. Observation on 12/10/18 from 5:30 p.m. to 5:50 p.m. revealed dietary aide (DA) R had brought the steam table to the third floor assisted dining room. During the observation time she: Had gloves on. Did not change them or perform hand hygiene while she poured drinks for the residents. Touched approximately half of the glasses with rims with her gloved hands. Also touched other surfaces including the countertop, wheelchair handles, and resident's skin, and clothing. Interview on 12/10/18 at 5:50 p.m. with DA R revealed she: Would have changed her gloves and washed her hands after she had brought the steam table to the dining room and before she started serving drinks. Agreed she had not changed her gloves or washed her hands during her time in the dining room. 2. Observation on 12/11/18 from 8:03 a.m. through 8:10 a.m. in the third floor assisted dining room revealed DA S: Served breakfast from the steam table. Had a glove on her left hand and no glove on her right hand. Used her gloved left hand to place bread in the toaster, remove the toasted bread, buttered the bread, cut the toasted bread in half, and placed it on residents' plates. Also used that same gloved left hand to place unpeeled hard boiled eggs on the residents' plates. Touched other surfaces with her left gloved hand and right ungloved hand during the breakfast service including: the kitchenette countertop, and opened and closed the toaster cart drawer, and the refrigerator door handle. Then took the glove off of her left hand and did not wash her hands. Helped a resident with cutting her toast. Went back to steam table, retrieved a glove out of the toaster cart drawer, put it on her left hand, and put an unpeeled hardboiled egg on a resident's plate. Then she removed that glove and without washing her hands returned to the steam table. Interview on 12/12/18 at 1:04 p.m. with the infection control registered nurse (RN) confirmed the observed practice was not the expectation of the provider. Review of the provider's undated Use of Plastic Gloves policy revealed: Plastic gloves would have been worn when handling food directly with hands. Hands were to have been washed before putting on the plastic gloves. A reminder Remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. 3. Observation and interview on 12/11/18 from 11:10 a.m. through 11:25 a.m. in resident 139's room with licensed practical nurse (LPN) F during a dressing change observation revealed: After performing hand hygiene LPN F put on a pair of gloves. She then: -Removed the items from the overbed table and placed them on top of the night stand. -Without cleaning the top of the overbed table she layed the clean supplies on the top of it. -Removed the old dressing from the resident's right front lower leg wound and discarded it in the garbage. -Removed her gloves and without performing hand hygiene put on a new pair of gloves. -Opened up a sterile syringe, opened up the vial of normal saline (NS), and drew up the solution into the syringe. -Flushed the right front leg wound with the NS and held a wash cloth beside the wound to collect any drainage from it. -Discarded the syringe. -Opened up a new gauze, soaked it with NS, wiped around the wound area, and discarded the gauze. -Removed her gloves, performed hand hygiene, and applied a new pair of gloves. -Wiped the scissors off with several alcohol pads and laid them on a Kleenex she had placed on the overbed table. -Removed her gloves, performed hand hygiene, and put on a new pair of gloves. -Packed the wound with new gauze and applied tape to it. -With the same pair of gloves on she: --Put the supplies back into the top dresser drawer. --Buckled the resident's right leg brace. --Discarded the unused NS. -Removed her gloves and without performing hand hygiene: --Placed the scissors and bottle of gauze strip back into the top dresser drawer. --Put on a new pair of gloves and removed the garbage. Interview on 12/11/18 at 4:07 p.m. with LPN F regarding the above dressing change for resident 139 revealed: She had missed a few hand hygiene opportunities during the dressing change observation. Any time she went from a dirty to a clean procedure or changed gloves she should have performed hand hygiene. Interview on 12/11/18 at 4:40 p.m. with RN/infection control nurse G regarding the above dressing change observation for resident 139 with LPN G revealed: Her expectations would have been for LPN G to have cleaned the overbed table and layed down a clean barrier before placing the dressing change supplies down. She agreed there were some missed hand hygiene opportunities between changing of soiled gloves to clean glove use. She should have done hand hygiene after each glove use. Interview on 12/12/18 at 8:01 a.m. with the director of nursing regarding the above dressing change observation of resident 139 with LPN G revealed there were some missed hand hygiene opportunities. Review of the provider's (MONTH) 2014 Dressing Changes Clean Technique policy revealed: Procedure: -2. Assemble necessary equipment. --Include a clean surface on which to place supplies. -5. Remove soiled dressing and discard into plastic bag. Remove gloves wash hands. Don new gloves. -6. Clean wound with Wound Cleaner or physician-prescribed cleanser. -7. Remove gloves and place in plastic bag. Wash/or alcohol hands. -8. Establish clean field and apply new gloves. -9. Perform treatment as ordered. -10. Remove gloves once dressing has been applied and wound covered. -11. Wash hands. 4. Observation on 12/11/18 at 8:51 a.m. of CNA U while assisting resident 73 with catheter care revealed: After performing hand hygiene CNA U put on a clean pair of gloves. With those clean gloves on she: -Opened the closet doors and took out clothes for the resident to wear for the day. -Moved the bedside table away from the resident's bed. -Assisted the resident with getting dressed. -Unhooked the catheter drainage bag from the bed frame and looped it through the resident's pants. -Moved the EZ stand mechanical lift closer to the resident. -Assisted the resident with placing her feet on the EZ stand base and secured the safety strap around her legs. -Went into the bathroom before transferring the resident and got two small towels. -Touched the water faucet handles without using a barrier and turned on the water. -After getting the towels wet she had turned off the water faucet. -Placed the clean towels on the edge of the sink and sprayed them with perineal cleanser. -Returned to the resident and assisted the resident to stand up using the mechanical lift. Without removing those soiled gloves and not washing/sanitizing her hands she washed the resident's perineal and catheter insertion site areas. The resident had been incontinent with a small amount of bowel movement. CNA U: -Removed her gloves and without washing/sanitizing her hands assisted the resident with pulling up her pants and transferring her into the wheelchair (w/c). -Put on a clean pair of gloves. With those gloves on she: -Touched the handles on the water faucet, turned it on without using a barrier, and turned on the water faucet. -Got the resident's dentures out of a container. -Rinsed the dentures under the water. -Turned the water faucet off without using a barrier. -Handed the resident her dentures to put in her mouth. CNA U removed her gloves and sanitized her hands at that time. 5. Observation on 12/11/18 at 8:19 a.m. with CNA X while assisting resident 60 with toileting and personal care revealed: After performing hand hygiene CNA X put on a clean pair of gloves. With those clean gloves on she: -Assisted the resident from his w/c, pulled down his pants and incontinent brief, and sat him down on the toilet. -Got two clean washcloths and placed them on the edge of the sink. -Touched the water faucet handles without using a barrier and turned the water on. -Wet the washcloths and placed them back on the edge of the sink. -Turned the water off without using a barrier. CNA X: -Removed her gloves and left the bathroom to retrieve some more supplies. -Sanitized her hands and put on a clean pair of gloves. With those gloves on she: -Assisted the resident to stand up. -Took the washcloths that had been sitting on the edge of the sink and used them to do perineal care for the resident. -Removed her gloves and assisted the resident to transfer to his w/c. -Sanitized her hands and assisted the resident out of the bathroom. Interview on 12/11/18 with CNA X at the time of the above observation revealed she: Confirmed the above process was her normal routine for assisting the resident with toileting and perineal care. Had not recognized the water faucet handles and the edge of the sink as dirty surfaces until after it was reviewed with her. Agreed her process was not sanitary and created the potential for cross-contamination of bacteria to have been transferred to the resident. 6. Observation on 12/11/18 at 9:17 a.m. with CNA W while assisting resident 103 with a transfer and personal care revealed: She had assisted the resident with transferring to her bed with the use of a mechanical lift. She positioned the resident on a bedpan to urinate. After she had performed hand hygiene again CNA W put on a clean pair of gloves. With those clean gloves on she: -Got a plastic garbage bag off a roll that had been placed on top of a sharps container. -Placed the garbage bag on the resident's bed. -Grabbed the bathroom door handle and opened the door. -Touched the water faucet handles without using a clean barrier and turned the water on. -Got two clean washcloths and wet them. -Removed the bedpan from underneath the resident and put it in the bathroom. -Used the washcloths to do perineal care for the resident. CNA W: -Removed her gloves and sanitized her hands. -Assisted the resident with pulling up her incontinent brief and pants. Interview on 12/11/18 with CNA W at the time of the above observation revealed she: Had not recognized the water faucet handles and the edge of the sink as dirty surfaces until after it was reviewed with her. Agreed her process was not sanitary and created the potential for cross-contamination of bacteria to have been transferred to the resident. 7. Interview on 12/11/18 at 10:35 a.m. RN/infection control (IC) nurse G regarding the above observations revealed she: Confirmed the above care provided for those residents had not been completed in a sanitary manner. Would have expected the CNAs to have removed their gloves and washed their hands after performing a task that had soiled their gloves. Agreed the above care had created the potential of cross-contamination of bacteria to be transmitted from one resident to another. Interview on 12/12/18 at 2:15 p.m. with the DON regarding the above observations of catheter and perineal care confirmed and supported the interview with RN/IC nurse [NAME] 8. Observation on 12/12/18 at 8:14 a.m. of LPN Q while passing medications revealed she: a. Gloved before and after drawing up insulin at the med (medication) cart in the hallway. Entered resident 74's room while the resident was in the bathroom. Injected insulin in her left abdomen then took her gloves off in the bathroom. Returned to the medication (med) cart. Washed her hands in the kitchenette for eight seconds. Returned to her med cart, entered information on her computer, and then gathered supplies. b. Observation on 12/12/18 at 8:23 a.m. revealed she: Returned to resident 74's room. Put on gloves. Washed the resident's bottom with a wet wash cloth. Changed her gloves without washing her hands. Applied [MEDICATION NAME] to the resident's pressure injury and took off her gloves. Went back to her med cart in the dining room. Entered computer information and put away the [MEDICATION NAME], then gathered supplies for the next resident. c. Observation on 12/12/18 at 8:40 a.m. revealed she: Entered resident 48's room. Gloved without washing her hands and rinsed out the resident's nebulizer face mask. Stated the mask was put back on holder without being rinsed. Rinsed the mask with water for approximately three seconds. Added the medication to the nebulizer (neb) chamber. The resident resisted putting the mask on. LPN Q held it in place for her. Remained with the same gloves on. Touched the resident, mask, and chair during her treatment. LPN Q rinsed out the mask and chamber. Took her gloves off and washed her hands for five seconds then returned to the med cart in the dining room. Then entered computer information and gathered supplies for the next resident. d. Observation on 12/12/18 at 8:56 a.m. of resident 3 in the hallway in a recliner revealed LPN Q: Entered the resident's room and added the medication to the chamber of the neb machine. Did not wash her hands nor put on gloves, took the neb machine to hallway, plugged it in, and touched the recliner and mask. Applied the mask to resident 3 who was sleeping in her chair. Adjusted personal clothing and touched her own hair. Rinsed out the mask in the resident's bathroom and placed it on the window sill. Returned neb machine to the window sill Returned to med cart and wiped her hands with paper towels. Went to the clean utility room and got a heating pad for resident 3. Applied it to resident 3's lower back while she was in the hallway in her recliner. Used hand gel for four seconds. Then charted, answered phone, took vital machine to an identified resident's room at 9:13 a.m. Did not wash her hands before entering that room. e. Observation on 12/12/18 at 9:23 a.m. of LPN Q revealed she: Returned to the med cart from an unidentified resident's room after getting vitals signs. Used hand gel for three seconds. Charted and put creams and supplies away in the cart. Interview on 12/12/18 at 1:21 p.m. with LPN Q revealed: She said she should have washed her hands and slowed down. She did not know the time according to the provider's policy that hands should be rubbed together after using gel. She was aware she should have washed her hands for twenty seconds after putting gloves on or taking them off. Interview on 12/12/18 at 1:43 p.m. with RN I revealed she would have expected LPN Q would have gelled or done handwashing before and after each glove use. Interview on 12/12/18 at 2:22 p.m. with the quality assurance (QA) coordinator revealed: She had done some audits on LPN Q's handwashing, and she did not do so well either. Audits were completed on 3/8/18 and 6/26/18. -Education was provided to LPN Q on those days. The purpose of those audits was to find out what was going on to provide a QA report. -Follow-up or education after those audits were not provided to LPN Q. -She stated she did not have time to do that. -She only works twenty hours a week and did not have time to follow-up. She did not do anything after the audit was completed. Interview on 12/12/18 at 2:44 p.m. with the DON revealed: She would have expected the QA coordinator to have followed-up with LPN Q. She did not have a job description for the QA coordinator. She would have expected handwashing with every glove change for at least twenty seconds. Review of the provider's (MONTH) (YEAR) Handwashing policy revealed: Policy: The spread of infection will be curbed by proper and frequent handwashing. Responsibility: Nursing staff - To follow proper procedure and indications for handwashing. Instructions: -1. Always wash hands: --a. Before and after contact with each resident. --c. After contact with blood or body fluids. --g. After contact with objects that have had resident contact and may be contaminated. --h. Between changing gloves. -6. Wash two inches above the wrist and for at least 15 seconds or longer. -10. Use waterless solution (hand gel) for 15 seconds or more if necessary.	2020-09-01
128	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2018-05-23	700	E	0	1	XUO711	Based on observation, interview, record review, and manufacturer's review, the provider failed to assess side rails for safety for ten of ten (1, 8, 9, 10, 14, 19, 27, 37, 38, and 41) residents who were randomly observed with side rails on their beds. Findings include: 1. Random observation on 5/21/18 from 12:30 p.m. through 5:45 p.m., on 5/22/18 from 7:00 a.m. through 5:45 p.m., and on 5/23/18 from 7:00 a.m. through 5:30 p.m. of residents 1, 8, 9, 10, 14, 19, 27, 37, 38, and 41 rooms revealed side rails were in the up position on each of their beds. Interview and record review on 5/23/18 at 8:00 a.m. with clinical care coordinator/licensed practical nurse [NAME] regarding side rails revealed: The side rail assessments were done quarterly. -They used to be in paper format, but now were in the electronic medical record. --Both forms had the same questions. The assessments had not clearly identified what safety aspects were reviewed. Review of the regulations related to side rails with him confirmed the assessments had not addressed whether: -Appropriate alternative interventions had been attempted prior to their use. -Appropriate installation and maintenance had occurred. -The risk of entrapment had been evaluated. -The risks and benefits had been reviewed with the resident or their representative. -Consent for use had been done prior to installation. -Manufacturers' instructions had been followed for the type of side rails being used. He confirmed side rails should have been evaluated for their safe use. Interview on 5/23/18 at 9:15 a.m. with clinical care coordinator/LPN [NAME] and clinical care coordinator/registered nurse (RN) F regarding side rail assessments revealed: They completed the side rail assessments quarterly. -Most residents used them for positioning and mobility. They had not discussed taking side rails off the beds of those residents who were not using them appropriately. They had not documented the safety aspects and risk of entrapment in the residents' medical records. RN F was unsure what role maintenance staff had in the documentation for proper installation, inspection, and maintenance of the side rails. All residents had some type of side rail on their beds. They confirmed side rails should have been assessed appropriately for safety. Interview on 5/23/18 at 2:45 p.m. with the director of plant operations revealed he: Never removed the side rails from the residents' beds unless they needed repair. Had not checked the side rails for safety on a routine basis. Had not included side rails on a preventative maintenance schedule. Agreed side rails should have been on his preventative maintenance schedule. Interview on 5/23/18 at 10:31 a.m. with the director of nursing (DON) regarding side rails revealed: She was aware the assessment had not clearly identified what safety aspects had been assessed. The assessment had been changed from paper to electronic format, but the questions remained the same. She confirmed the side rail assessment had not addressed all the areas required from the regulations such as: -Risk of entrapment. -Risk and benefits. -Proper consent for use. -Appropriate installation, inspection, and maintenance. The safety assessments had not been clearly documented or assessed. *All residents had some type of side rail on their bed. -They had done quarterly assessments of side rails. Interview on 5/23/18 at 3:27 p.m. with the administrator, DON, previous administrator, and clinical care coordinator/LPN [NAME] revealed the provider had no policy regarding bed or side rails or the use of them.	2020-09-01
129	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2018-05-23	758	D	0	1	XUO711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (38) had documentation to support [MEDICAL CONDITION] medications had been administered appropriately. Findings include: 1. Observation on 5/22/18 of resident 38 revealed: At 7:37 a.m. he was sleeping in his bed. At 8:38 a.m. he was sleeping in his bed. At 10:18 a.m. he was sitting in his wheelchair in his room. Review of resident 38's medical record revealed: He was admitted on [DATE]. He had [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behaviors. -Muscle weakness. -Unsteadiness when on his feet. -Anxiety. -Dementia with behaviors. -Altered mental status. Review of resident 38's 12/19/17 psychiatric examination revealed: He Continues to have behavioral issues with resisting cares at times and agitation. He is given the prn (as needed) [MEDICATION NAME] and the prn [MEDICATION NAME] most days at least one time and sometimes more. He will continue on these medications and staff should monitor his medication use and behavioral response. Review of resident 38's (MONTH) (YEAR) consultant pharmacist's medication regimen review (MRR) revealed: I was reviewing his (MONTH) (YEAR) eMar (electronic medication administration record) to follow the use of [MEDICATION NAME] and [MEDICATION NAME]. -The use of these 2 agents appear to coincide with no time between doses to allow for 1 agent or the other to work. -This results in not knowing what, if anything is working. -We should use 1 agent at a time and document the results. Hand written note in Follow through area of document stated Education provided to staff. (name) LPN (licensed practical nurse) 4/10/2018. Review of resident 38's (MONTH) (YEAR) consultant pharmacist's progress note revealed: [MEDICATION NAME] use for (MONTH) (YEAR) was eighteen tablets, and [MEDICATION NAME] use was thirteen tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was fifteen tablets, and [MEDICATION NAME] use was twenty tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was fourteen tablets, and [MEDICATION NAME] use was twenty-two tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was twenty-one tablets, and [MEDICATION NAME] use was twenty-two tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was twenty-four tablets, and [MEDICATION NAME] use was twenty-five tablets. [MEDICATION NAME] and [MEDICATION NAME] use appear to coincide with no time between doses. -Results in not knowing what, if anything is working. -Should use 1 agent at a time to monitor the success of treatment. -Sent nursing a note in 4/2018 MRR. -Noted pt. (patient) (resident) continues to get these medications simultaneously. Review of resident 38's (MONTH) (YEAR) physician's orders [REDACTED].>[MEDICATION NAME] 0.5 mg tablet PO (by mouth) Q (every) 6 hour's prn for agitation. [MEDICATION NAME] 50 mg tablet. -Give 1/2 tab of 50 mg to equal 25 mg by mouth every 6 hours as needed for agitation. Review of resident 38's (MONTH) (YEAR) medication record revealed: Between 4/1/18 and 4/30/18: -[MEDICATION NAME] and [MEDICATION NAME] tablets were given together twenty-three of twenty-four times. -They were given within a minute of each other one of twenty-four times. -They were given between the hours of 8:00 p.m. and 12:15 a.m. Review of resident 38's (MONTH) (YEAR) medication record revealed: Between 5/1/18 and 5/22/18: -[MEDICATION NAME] and Trazadone tablets were given together eleven of eighteen times. -They were given within a minute of each other four of eighteen times. -They were given between the hours of 5:19 p.m. and 11:53 p.m. Interview on 5/23/18 at 10:35 a.m. with clinical care coordinator F revealed: She did not know why two prn meds were being given at the same time.She would research it and get back to this surveyor.On 5/24/18 at 3:00 p.m. no response from care coordinator F had been received regarding resident 38's prn orders. Interview and record review on 5/23/18 at 1:10 p.m. with the director of nursing regarding resident 38 revealed: He usually had behaviors at night. She agreed both medications had been given together all but six times in April. There was no documentation two prn medications could not be given together. She agreed the effectiveness of a prn medication needed to be evaluated. Interview and record review on 5/23/18 at 2:30 p.m. with LPN [NAME] revealed: It was his hand written note on the consultant pharmacist's MMR for (MONTH) (YEAR) Education provided to staff on 4/10/18. He had only educated one nurse. -He had only reported findings of pharmacist to her. -Had no documentation education with that one nurse had taken place. Review of the provider's 7/19/12 Medication Regimen Review policy revealed: Purpose: -All residents will have their medication regimen reviewed on a monthly basis and as needed to ensure the regimen is being managed appropriately and is free from unnecessary medications. Procedure: Medication management refers to consideration of: -Indications for use of the medication (including initiation or continued use of psychoactive medication). -Monitoring for efficacy and adverse consequences. -Dose (including duplicate therapy). -Duration. -Tapering of a medication dose/gradual dose reduction for antipsychotic medications. -Prevention, identification, and response to adverse consequences.	2020-09-01
130	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	253	D	0	1	POHR11	Based on observation, testing, interview, and record review, the provider failed to maintain the following items in a sanitary and/or safe condition: One of two beauty shop styling chairs was in need of a deep cleaning. One of one housekeeping central supply area had chemicals and cleaners stored so as to create possible contamination to hygienic paper goods. Findings include: 1. Observation on 5/23/17 at 9:00 a.m. revealed a yellow vinyl stylist chair in the beauty shop. That vinyl chair had a build-up of dirt and grime in the grooves that made the yellow color appear brown. Testing by running a fingernail across the chair left a clean trail of the color yellow beneath the removed grime. Interview with the beautician at the time of the observation and testing confirmed that finding. She stated she was a substitute that day for the regular beautician, but the chair appeared to need a deep cleaning. Interview on 5/23/17 at 9:00 a.m. with director of environmental services confirmed: The chair was dirty and appeared brown when the color of the chair was yellow. Housekeeping was responsible to clean beauty shop furniture and the floor at the end of each day. Review of the weekly room deep cleaning schedule revealed the beauty shop was not listed on any day of the week nor the week-ends. 2. Observation on 5/23/17 at 4:25 p.m. of the housekeeping central supply area revealed wire mesh shelves. Those shelves held large rolls of paper towels used to fill paper towel dispensers in handwashing locations. Those large rolls of paper towels were stored in direct contact and next to stainless steel polish, Clorox urine remover, Clorox bleach germicidal, and Kleenex foam skin cleanser. Interview on 5/23/17 at 4:25 p.m. with director of environmental services confirmed: Paper products and chemicals should not have been stored together on the same shelf. Chemicals should not be have been stored above paper products. The large paper towels could be contaminated from the chemicals 3. Continued interview on 5/24/17 at 3:00 p.m. with the director of environmental services and the administrator revealed: There were no logs to identify when beauty shop furniture was cleaned or when the beauty shop had received a deep cleaning. There were no policies for the cleaning of beauty shop furniture. There were no polices on the storage of hygienic paper products with chemicals.	2020-09-01
131	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	309	E	0	1	POHR11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy review, and contract review, the provider failed to ensure communication and documentation for hospice services had been incorporated into the medical records for two of three sampled hospice services residents (4 and 5). Findings include: 1. Review of resident 5's medical record revealed: He had been admitted on [DATE]. A hospice referral had been physician ordered on [DATE]. He had been admitted to hospice services on 3/29/17. The provider's plan of care (P[NAME]) dated 3/31/17 had been revised and had added I am on hospice. Please see hospice care plan for additional options. -That P[NAME] was located in his record at the nursing station. No hospice care plan had been identified in his medical record. Interview on 5/24/17 at 7:40 a.m. with the social services coordinator revealed she: Expected a hospice care plan to be located in the resident's paper chart at the nursing station. Confirmed the provider's current P[NAME] stated: -The resident was on hospice care. -See the hospice care plan for additional information. Interview on 5/24/17 at 9:35 a.m. with registered nurse (RN) A regarding care for residents who received hospice services revealed she: Would have looked at the hospice tab in the resident's paper chart to know how to care for the resident. Was not able to locate a hospice tab in resident 5's paper chart. Was not sure what services hospice provided or how often they visited the resident. Interview on 5/24/17 at 7:45 a.m. and at 2:50 p.m. with the director of nursing services regarding resident 5's care plan revealed: The hospice care plan was not in the facility as of 5/23/17 when it had been requested by the surveyor. The process would have been to have a Hospise care plan in the medical record. She would have expected to have found it in the paper chart at the nurses station. They would refer to the hospice care plan when information was needed on hospice services. She confirmed the P[NAME] only stated I am on hospice. Please see hospice care plan for additional options. Review of the provider's 6/17/15 Interdisciplinary Care Plan policy revealed: The resident's physician and/or other primary health care providers can be integral to this process. The care plan should be updated When there has been a significant change in the resident's condition 2. Review of resident 4's medical record revealed: An admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. -Comfort care order set to initiate if needed. -Hospice consult. A RCRH Hospice of the [NAME]s visit dated 2/27/17. -That note stated the hospice physician had not approved the resident for hospice, and to check back on patients status in one week. There had been no further documentation in the resident's medical record regarding a hospice consult. Interview on 5/23/17 at 2:00 p.m. with RN B revealed: No further documentation in resident 4's medical record regarding the hospice consultation ordered on [DATE]. She stated she was pretty sure the hospice nurse had come again to see the resident but had not known when. She had been unsure of the status of the resident's hospice consult. She stated she would contact the hospice agency for the information. Interview and record review on 5/23/17 at 2:45 p.m. with RN B revealed she had obtained three hospice notes from the agency. The first note on 3/7/17 stated the resident had not met the hospice criteria and would be re-evaluated in two weeks. -The above visit had been completed with the Social worker and nurse at facility. -No documentation had been entered into the resident's medical record regarding that visit. The second note on 3/21/17 stated Explained to pt (resident) that she was ill enough that we had been referred to evaluate her for hospice but that now she has bounced back to her baseline and she is in agreement that hospice is not what she would desire at this time and acknowledges that she has recovered from her post surgery issues. Will request this referral be closed. -No communication with the provider had been identified. A third note on 5/9/17 stated:- Hospice consult done 5/9/17 at (name) nursing home. She had been seen X3 for previous hospice referrals in Feb and (MONTH) following hospital stay for fracture of distal femur and difficulty recovering from surgery to stabilize this. -Dr. (name) was spoken with today at 1330 (1:30 p.m.) and does not approve of pt meeting criteria for hospice at this time. -Discussed case with staff at (name), her RN caring for her today and also RNs B and C at the facility. RN B agreed: -The hospice notes had not been available in the resident's medical record. -The provider had not documented in the resident's medical record about the above Hospice consultation visits. Interview on 5/24/17 at 2:50 p.m. with the director of nurses regarding resident 4 revealed she agreed:The hospice consult documentation had not been available in the resident's medical record. Their only documented communication between the provider and Hospice in the resident's medical record had been on 2/27/17. Review of the provider's signed 12/1/8 contract with the Hospice provider revealed: The Home and Hospice agree to cooperate in the facilitation of open and clear communication in order that the needs of patients are addressed and med 24 hours per day. Such communication shall include the sharing of all relevant records and other information regarding a patient. The Hospice shall furnish a copy of such Plan of Care for such resident to the Home at the time of the resident's admission into the Hospice program. The Hospice shall provide to the Home the following subject to the patient's consent, access to all records of hospice services rendered to the patient.	2020-09-01
132	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	323	D	0	1	POHR11	Based on observation, testing, and interview, the provider failed to ensure housekeeping cleaners and disinfection chemicals were not accessible to residents in the following areas: One of two therapy rooms (restorative). One of one shared bathroom between two of two therapy program rooms. Findings include: 1. Observation on 5/23/17 at 3:40 p.m. of the restorative therapy (RT) room revealed: The corridor door to the room was wide open. No one was in the room, but residents were noted in the corridor. A tall wooden cabinet had a key in the door. -Testing of that door revealed it had been left ajar. -A shelf in that cabinet had a container of Sani-Cloth Plus disinfectant wipes. Continued observation of the shared bathroom between the RT program room and the physical/occupational therapy (PT/OT) room revealed: The corridor door to the PT/OT room was wide open. No one was in the room, but residents were noted in the corridor. Both bathroom doors were opened between the two rooms. -All residents had access to that bathroom. Two containers sat next to each other on the tank of the bathroom toilet. Those containers were: -A flat package of resident personal care wipes commonly used for personal hygiene. -A round container of Sani-Cloth Plus disinfectant wipes. --Review of that Sani-Cloth Plus label revealed: ---They were germicidal disposable cloths. --Precautionary statement read: ---Hazards to human and domestic animals. ---Not for use on skin. Interview on 5/23/17 at 3:40 p.m. with the director of environmental services confirmed: The disinfection wipes were used on equipment in the therapy programs. Sani-Cloth Plus wipes should not have been stored accessible to residents. The wooden cabinet in the RT room should have been locked, and the key removed from the door. The Sani-Cloth wipes in the bathroom should have been stored in a locked cabinet. Interview on 5/24/17 at 9:25 a.m. with the occupational therapist revealed she: Was not aware the Sani-Cloth disinfectant wipes should not have been stored in the bathroom. Confirmed the other disinfectant wipes used throughout therapy were in a locked cabinet. Concluded the container of Sani-Cloth wipes in the bathroom would be a hazard to residents and also should have been locked and inaccessible with the other disinfectant wipes. Felt Worried if the wipes were stored with the hygiene wipes in the bathroom, a resident could have mistaken the wrong wipe. Interview and testing on 5/24/17 at 12:05 p.m. with licensed practical nurse H who was the restorative therapist revealed she: Confirmed the key to the cabinet was still left in the unlocked cabinet, and the door to the RT room was lefted opened. Usually removes the key and puts it in my pocket. Which she did at that time. Was aware the cabinet should have been locked and inaccessible to residents, because the disinfectant wipes were stored in that cabinet. Interview on 5/24/17 at 3:00 p.m. with the director of environmental services and the administrator revealed there were no polices on the storage of chemicals and cleaners and their accessibility to residents.	2020-09-01
133	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	431	F	0	1	POHR11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the provider failed to ensure medical supplies were not outdated in: One of one therapy room for one two gallon container of ultrasonic gel that had expired (MONTH) (YEAR). One of one central nurses supply area for: -Five of five sodium chloride 500 milliliter (ml) irrigation solution expired (MONTH) (YEAR). -Three of three bottles of 70% isopropyl alcohol 16 ounces (oz) expired (MONTH) 2014. -Five of five hydrogen peroxide 16 oz expired (MONTH) (YEAR). Two of two treatment carts: -Two boxes filled with 3 ml sodium chloride (NaCl) expired plastic vials. --Those expiration dates ranged from (MONTH) 2014 through (MONTH) (YEAR). -Two 16 oz bottles of hydrogen peroxide expired (MONTH) (YEAR). One of one medication room for three of three intravenous (IV) solutions that had expired (MONTH) (YEAR). Findings include: 1. Observation on [DATE] at 3:45 p.m. of one of two therapy rooms revealed an in-use, approximately two gallon plastic flexible container of Ultrasonic Gel that had expired (MONTH) (YEAR). That container had been opened and approximately an eighth of the gel was left. Interview at the time of the above observation with the director of environmental services confirmed: Expired items should have been discarded. Therapists were responsible for checking expiration dates on their supplies. Interview on [DATE] at 9:25 a.m. with the occupational therapist revealed: They used that large container of gel to fill the small squirt bottles throughout therapy. They had not checked the expiration date before they filled the small squirt bottles. She was not aware the ultrasonic gel had an expiration date. 2. Observation on [DATE] at 4:25 p.m. of the nursing central supply area revealed the following: Five sodium chloride irrigation 500 ml bottles had expired (MONTH) (YEAR). Three 16 oz bottles of 70% isopropyl alcohol had expired (MONTH) 2014. Five 16 oz bottles of hydrogen peroxide had expired (MONTH) (YEAR). Interview at the time of the above observation with the director of environmental services revealed: Those expired items should have been discarded. Nursing services was responsible for checking that area for expired medical items. Items from the nurses supply area would have been used for resident's care. 3. Observation on [DATE] at 2:25 p.m. of both treatment supply carts used for hallways Maple, Aspen, Oak, and Elm revealed: Both carts contained a box filled with 3 ml NaCl plastic vials. -Several of those NaCl vials had expiration dates from (MONTH) 2014 through (MONTH) (YEAR). The bottom drawer of both carts contained a 16 oz bottle of hydrogen peroxide that had expired (MONTH) (YEAR). The bottles had been opened, and three-fourths of the solution had been used. Interview on [DATE] at the time of the above observation with the director of nursing services (DNS) and registered nurse (RN) A revealed: They were not sure from where and when the above items had been restocked. The staff had the capability of obtaining supplies from the basement and other supply rooms on the hallways. They were not aware the above items had expired. The pharmacist and RN A would have checked the treatment cart every month for outdated supplies. -Any expired items should have been returned to the pharmacy department. 4. Observation on [DATE] at 2:48 p.m. with licensed practical nurse (LPN) [NAME] of the medication room revealed: The cabinets and drawers contained multiple resident use items such as medications, treatment supplies, a container filled with IV supplies, and a locked medication emergency kit (Ekit). On the shelf next to the Ekit was a small plastic bag. That plastic bag held three 100 ml IV bags filled with 0.9 percent (%) NaCl with the expiration date (MONTH) (YEAR). Interview on [DATE] at the time of the above observation with LPN [NAME] revealed: He confirmed the above observation of the expired IV fluid filled bags. He had not been aware they were in that cabinet or from where they had been restocked. The pharmacist should have checked the Ekit and IV supplies for outdates every month. 5. Interview on [DATE] at 4:00 p.m. with the administrator revealed they did not have a policy and procedure in place to ensure outdated items were properly disposed of and replaced. Nursing services and the pharmacist was responsible for checking for expired medical items and medicine. Interview on [DATE] at 6:30 p.m. with the facility pharmacist confirmed he checked the medication carts, treatment carts, Ekit, and IV supplies every month for outdates. He had not been aware of any IV fluid bags located in the cabinet by the Ekit. He was not sure where they had come from and who had placed them there. The only IV supplies he checked for outdates every month were located in the container in the cupboard. He had not been informed of any IV supplies located in the basement of the facility.	2020-09-01
134	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	441	F	0	1	POHR11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, testing, label review, document review, and interview, the provider failed to ensure: One of one sampled resident (1) on isolation precautions was treated in a manner to control and prevent the spread of the disease to other residents, staff, and visitors. Two of two bath aides (J and K) followed manufacturer's directions for disinfection of two of two whirlpools. Dishware, utensils, cookware, and extra kitchen items were protected from possible contamination from an overhead sewer line in one of one basement kitchen storage room. One of one [MEDICATION NAME] wax hand therapy basin was cleaned in accordance to the manufacturer's directions. Medical supplies, resident hygienic use items, wound care supplies, and medication pass supplies were stored protected from possible contamination in one of one basement nursing supply storage room. Clean linens from three of three washers were protected from possible contamination by one of one dirty wall mounted oscillating fan. Findings include: 1.a. Observation on 5/23/17 at 7:10 a.m. of resident 1's doorway revealed: The door to her room was shut. On top of a plastic cart in the alcove by her room was: -A box of gloves. -A laminated sign with gloves, gown, and a mask written on top of it. -Next to the word glove was a check mark. Inside the three drawers of the cart were red garbage bags, disposable gowns, masks, and gloves. There was no signage in the immediate area indicating visitors, staff, and residents should visit with the nurse prior to entering that room. Interview at the time of the above observation with registered nurse (RN) F revealed: The resident had: -Been placed on isolation precautions on 5/20/17 for a [DIAGNOSES REDACTED]. -Required contact isolation precautions. She confirmed there was no sign in the immediate area indicating visitors, staff, and residents should have checked with nursing prior to entering her room. But we do have signs. She stated She just has shingles. She questioned Don't you think that would reveal to much information? She agreed: -Shingles was an infectious disease. -Those who were pregnant or never had the chicken pox virus were at risk for acquiring chicken pox should they have been exposed or came in contact with the resident. She stated A sign would probably be a good idea. Observation on 5/23/17 at 9:50 a.m. of resident 1's room revealed: The door was open to the corridor. The above mentioned plastic caddy remained unchanged. A sign located above that plastic caddy read Please check with nurse before you enter the room. Review of resident 1's medical record revealed: On 5/17/17 the staff had identified an area of concern on the left side of her breast that had extended down the left side of her [MEDICATION NAME] spine. On 5/20/17 the area had worsened and the physician had given her a [DIAGNOSES REDACTED]. Surveyor: 1.b. Interview on 5/23/17 at 1:30 p.m. with bath aide/CNA K revealed they used the disinfectant for the whirlpool for all residents. If a resident was diagnosed with [REDACTED]. That was the only time a resident actually received a shower. She stated all residents received a whirlpool. Some may be a little hesitant at first, but after a few times they got used to the whirlpool. She was not aware if the whirlpool disinfectant was effective against shingles. She was aware resident 1 had shingles, but she had not been told to use the shower or another disinfectant. Interview on that same day at 1:45 p.m. with bath aide/CNA J confirmed the above interview with bath aide/CNA K. She too used the whirlpool disinfectant and only gave showers if there was a case of [DIAGNOSES REDACTED]. Continued interview with both bath aides/CNAs J and K revealed they also used MadaCide Germicidal Solution to disinfect fingernail clippers, toenail clippers, toenail nippers, and any other item for resident nail care that could be disinfected. They stated they used the same instruments for nail care on all residents but would disinfect them between use. Review of the MasterCare Bath whirlpool disinfectant label revealed it gave no information it was effective against shingles. Phone interview on 5/23/17 at 3:00 p.m. with the company's chemist for the disinfectant revealed it was not effective against shingles. Review of the Madacide Germicidal Solution label revealed it gave no information it was effective against shingles. Surveyor: Observation and interview on 5/23/17 at 2:50 p.m. of resident 1 with RN F confirmed the resident had just received a bath. Observation on 5/24/17 at 10:45 a.m. of resident 1 with RN F revealed: She had a loose shirt on that covered her shingles. The shingles continued to be red. The blistered areas had increased and were filled with yellow colored fluid. Interview on 5/24/17 at the time of the above observation with RN F revealed: The resident: -Received baths on Tuesday and Friday. -Was the last one to have received a bath that day due to her shingles. She was not sure: -What type of isolation or contact precautions the resident had required. -If the chemical they were using to clean the tub was appropriate for someone with shingles. She would have relied upon RN C to ensure the correct infection control processes were in place for the resident. She was not sure why they would have treated this infectious disease any different than the other types. She agreed they had been more reactive versus proactive when ensuring the other residents were not exposed to that infectious disease. Interview on 5/24/17 at 11:15 a.m. with the director of nursing services (DNS) revealed: She had been the infection control nurse for the facility and was aware resident 1 had shingles. The resident had resided on the Oak hallway, and those twelve resident's received baths on Tuesday and Friday. She stated A majority of the residents received baths. She could not confirm if resident 1's shingles had been opened and draining, as she had not done a skin check. She would have relied upon RN C to determine the amount of restriction required for the resident. She stated We are not gonna isolate beyond restriction. If the blisters are not draining we would continue to accommodate the resident's wishes. So if she preferred a bath we would give her a bath. I'm not sure if they are draining I would have to check with (RN C's name). Surveyor: Interview on 5/24/17 at 8:00 a.m. with housekeeper I revealed they had been told to use the 3M quaternary disinfectant 5L and 5H for all the resident rooms and at the end of the day in the bathing rooms. They would use Clorox Healthcare Bleach Germicidal Cleaner for rooms with clostridium difficile (C. Diff.). That was the only time they would use the Clorox cleaner was when there was a case of [DIAGNOSES REDACTED]. The 3M disinfectant took care of all other viruses. Review of the technical data information sheet for the 3M product was not effective against shingles (Herpes [MEDICATION NAME]). Interview on 5/24/17 at 2:05 p.m. with the DNS revealed: She was the infection control nurse for the facility. They would use Centers for Disease Control (CDC) or the local hospital's infection control program as references. She was aware resident 1 had been diagnosed with [REDACTED]. She would not have educated the housekeeping staff or the two bath aides to use a different disinfectant for a [DIAGNOSES REDACTED]. All the cleaning chemicals we use for housekeeping should take care of body fluids except for [DIAGNOSES REDACTED]. For [DIAGNOSES REDACTED]. we would use bleach. We would use the MasterCare product for the disinfections of the two whirlpools except if a resident has [DIAGNOSES REDACTED]. She was not aware if any of the staff who provided care to resident 1 had received any precautionary vaccines to prevent shingles. She had referred to RNs B and C to include infection precautions and education to staff for the care of resident 1. Interview on 5/24/17 at 2:25 p.m. with the RNs B and C revealed they: Were not aware the 3M products used in housekeeping, the MasterCare whirlpool disinfectant, and the Madacide used for resident nail care was not effective to kill the shingles virus. Both thought the products they were using took care of everything except [DIAGNOSES REDACTED]. Had not educated the housekeepers or the bath aides on the use of a different disinfectant as they had been told the above listed products were sufficient in the control of the shingles virus. Confirmed they had not reviewed the labels of the above listed products or investigated further if those products were suitable for the shingles virus. Confirmed they used the CDC guidelines for infection control. Review of the Clorox Healthcare on-line information revealed Ultra Clorox Germicidal Bleach was effective at disinfection of [MEDICATION NAME]-[MEDICATION NAME] virus (shingles) with a five minute contact time. 2. Interview on 5/23/17 at 1:30 p.m. with bath aide/CNA K revealed they used the MasterCare Bath disinfectant for the whirlpool for all residents. She was unsure of the contact time for the whirlpool disinfectant but thought it might be around ten minutes. She had received training on how to use and disinfect the whirlpools when she became a CNA at the facility about a year ago. She then proceeded to: Fill the whirlpool with the disinfectant. Run the whirlpool jets. Scrub all surfaces to include the bath chair with the whirlpool disinfectant. Spray the disinfectant again over all surfaces. Turn the disinfectant hose off and use the shower hose to rinse the tub and the bath chair. The entire process from start to finish took one minute and thirty seconds. Interview on that same day at 1:45 p.m. with bath aide/CNA J confirmed the above interview with bath aide/CNA K. She too used the whirlpool disinfectant and thought it might be about a ten minute contact time. She had also been trained on how to use and disinfect the whirlpools when she became a CNA about two years ago. She then proceeded to complete the same above steps for the disinfection of the tub, its surfaces, and the bath chair. Her entire disinfection and rinsing procedure took two minutes and thirty seconds. She stated she and bath aide/CNA K were the only two bath aides. If a bath was needed on the week-ends it was given by another CN[NAME] 3. Observation and interview on 5/23/17 at 3:30 p.m. with the dietary service manager revealed:Extra dishware, utensils, cookware, and kitchen supply overflow were on shelves in the basement. Those items were in close contact or located under a sewer line. She agreed those items had been stored and created a possible contamination from the sewer lines. Review of the provider's undated Care of the Storeroom policy revealed no procedure for keeping items free from possible contamination. Surveyor: 4. Observation on 5/23/17 at 3:45 p.m. revealed a TherabathPRO [MEDICATION NAME] bath unit in a room in the therapy area. The cloudy wax was melted, and there was a very large amount of sediment in varying colors on the bottom of that unit. Interview at the time of the observation with the director of environmental services confirmed that finding. Interview on 5/24/17 at 9:25 a.m. with the occupational therapist revealed she was not aware when the last time the [MEDICATION NAME] wax had been changed and when the unit had been cleaned. She stated it would have been formal protocol to replace the wax when there was sediment in the bottom of the unit. There was no official log to keep track of cleaning the [MEDICATION NAME] bath. Review of the undated on-line Therabath [MEDICATION NAME] bath guidelines revealed Clean the TherabathPRO after every 25 treatments, when the [MEDICATION NAME] is cloudy, or when sediment accumulates on the bottom of the unit. 5. Observation on 5/23/17 at 4:25 p.m. of one of one nursing central supply area in the basement revealed: Cardboard boxes of oral syringes, toothpaste, volumetric exercisers, urinary collection bags, adhesive dressings, and gauze were stored on the floor. Two metal shelving units had chipped and peeling paint, rust, areas of spilled liquid debris, and layers of dirt and dust. Those shelves were used to store medical supplies. Emesis basins, bath basins, graduated measuring containers, specimen hats, plastic drinking cups, plastic teaspoons, and irrigation syringes were stored directly under condensation drainage pipes and sewer lines. Interview on 5/23/17 from 4:40 p.m. to 5:00 p.m. with the director of environmental services confirmed: Items should not have been stored on the floor. Shelving with exposed bare metal was not a cleanable surface and created an infection control risk. The metal shelves needed a deep cleaning and repair. Drainage pipes should not have had resident use items stored directly under them. 6. Observation on 5/23/17 at 4:55 p.m. of the laundry room revealed: A wall mounted oscillating fan cover and blades were covered with dust and lint. -That dust and lint covered the white grill and blades and made it gray in color. The dust and lint had layered on the fan, had begun to trail down the outside of the cover, and hung like thick cobwebs from the grill. That fan was located directly above three washing machines. *Clean linen could have become contaminated when removed from those three machines. Interview on 5/23/17 from 4:40 p.m. to 5:00 p.m. with the director of environmental services confirmed the oscillating fan cover and blades in the laundry area were covered with lint, dust, and debris. He stated it was the laundry staffs' responsibility to keep the fan clean. Interview on 5/24/17 at 3:30 p.m. with the administrator revealed the fan was not on the housekeeping list for the laundry personnel.	2020-09-01
135	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2019-08-14	657	D	0	1	BSIS11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure 1 of 13 sampled residents' (24) care plans were updated and revised to reflect the resident's current status and care needs. Findings include: 1. Random observations on 8/12/19 between 1:03 p.m. and 5:30 p.m. of resident 24 revealed: She had required assistance from one staff person to transfer her from wheelchair to bed. -She had been in bed most of that afternoon. Staff had pushed her in the wheelchair to the dining room for dinner at 5:05 p.m. -She had required verbal and physical assistance from staff to eat. -She had hung her head and kept her eyes closed for most of the meal. -Her intake was poor. Random observations on 8/13/19 from 7:30 a.m. until 10:58 a.m. of resident 24 revealed: She was asleep in bed between 7:30 a.m. and 9:35 a.m. She had been pushed in her wheelchair by staff to a common area at 10:58 a.m. to listen to staff read the news. -Her head was down, and her eyes were closed during that activity. Review of resident 24's medical record revealed: Her [DIAGNOSES REDACTED]. She had weighed 92 lb (pound) on 3/23/19 and had weighed 82.5 lb the week of 8/5/19. She had become physically weaker in the last few months. On 7/24/19 her physician had ordered all nutritional supplements be stopped and had continued only medications that had helped the resident remain comfortable. Review of resident 24's 6/22/19 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status score was three indicating severe cognitive impairment. Interview on 8/14/19 at 1:30 p.m. with clinical care coordinator A included review of resident 24's last updated 7/29/19 care plan and revealed: a. Activities of Daily Living Function: I have a restorative program d/t (due to) decreased endurance and balance precautions, overall weakness and lack of motivation. Start date was 10/18/18. -That program had included mobility, standing, wheelchair leg press, pivot transfers, and upper extremity exercises two to three times per week. The clinical care coordinator confirmed there had been no restorative program documentation from 8/1/19 to 8/14/19. She was uncertain if the program was still implemented. It was expected if a restorative program was no longer provided it would have been removed from the care plan. b. Mood State: I am visited by spiritual support to assist with my mood. Start date was 4/8/15. -The clinical care coordinator had found no documentation to indicate the resident had been seen for spiritual support. -She agreed spiritual support was appropriate for the resident due to recent changes in her treatment goals. c. Behavior Problem: My behaviors are wandering, inappropriate behaviors and rejecting care. Start date 12/28/15. -The clinical care coordinator confirmed there was no documentation from 8/1/19 to 8/14/19 in the plan of care daily charting of wandering behavior. -She was uncertain if the resident had still exhibited wandering behavior. -She agreed the care plan should have been reviewed and updated if wandering was no longer a behavioral concern. d. Falls: I self transfer despite fall risk and I do not use my call light to seek staff assistance. Promote my success when I self transfer by placing my bed at natural height and locking my wheelchair next to bed when I lay down. No floor mats. Start date 4/10/15. Low bed with mat in place when in bed. Start date 7/11/19. The clinical care coordinator had stated approaches should be consistent throughout the care plan. e. Pressure Ulcers: I have a pressure-relieving device air mattress overlay, gel cushion to wheelchair. Start date 3/24/15. The resident had a non-removable wedge in the middle and front edge of her wheelchair seat. -The clinical care coordinator had thought a physical therapist had fitted the resident's wheelchair with that device sometime in (MONTH) 2019. -It was the expectation of the clinical care coordinator if the wedge was used for positioning it should have been care planned. I receive 2 cal (nutritional supplement) per MAR (medication administration record) for nutritional support and to facilitate skin integrity. Start date 5/25/15. -There was no physician's order on the resident's (MONTH) 2019 MAR for 2 cal. -The clinical care coordinator agreed that care plan approach was not accurate and should have been discontinued. Continued interview at 2:10 p.m. revealed: The facility had two clinical care coordinators who were responsible for the scheduling, completion, and submission of residents' MDS assessments. They were responsible for developing, updating, and discontinuing nursing and therapy related resident care plan problems, goals, and approaches. They each had a specific caseload of residents they were responsible for, but they were expected to fill each others roles as needed. It was expected care plans were reviewed and updated when MDS assessments had been completed. Care plan changes were made more frequently based on resident information shared during daily stand up meetings. Resident 24's plan of care had not been updated to reflect her current care needs. Review of the provider's 6/17/15 Care Plan/RAI (Resident Assessment Instrument) Process policy revealed: 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.	2020-09-01
136	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-01-31	689	E	1	0	NOYG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, and policy review, the provider failed to ensure: Timely preventative maintenance to include checking lift clips for one of three total mechanical lifts (2) to prevent a fall for one of one sampled resident (1). Staff education and training for all direct care staff including four of four interviewed certified nurse assistants (CNA) (A, B, C, and D) about proper usage, sling selection, and appropriate maintenance of total mechanical lifts when used with sampled residents 1, 4, and 5. Findings include: 1. Review of resident 1's 1/18/18 South Dakota Department of Health (SD DOH) event report revealed: Certified nursing assistants (CNA) D and F had been transferring the resident into her wheelchair with the total mechanical lift. The sling hooked on the right front hook slide off Hoyer hook when sling was pulled back to sit resident straight into her w/c (wheelchair). The resident fell forward and hit the right side of her head on the floor. The lock on the right hook did not go into lock position causing the right sling hook to slide off Hoyer. The equipment malfunction was written up for the maintenance department, and the Hoyer lift had been removed from the floor. The report had been completed by licensed practical nurse [NAME] Observation on 1/30/18 at 3:50 p.m. in the 100 hallway revealed on Hoyer lift 4 one of four clips was broken. Interview on 1/31/18 at 9:00 a.m. with CNA D regarding resident 1's fall out of the lift revealed: She had been employed at the facility for approximately sixteen years. They had been using the total mechanical lift labeled 2. All four clips had been broken on the lift prior to transferring resident 1 on 1/18/18. The clips had been broken for awhile, but she was not sure how long they had been broken. She had not reported the broken clips to maintenance. She had not had training on proper use and maintenance of the lifts since she had been employed. The resident had fallen forward and hit her head. Review of the mechanical lift preventative maintenance record for lift 2 revealed: The following items had been on the list to check: -Emergency lowering. -Chassis function. -[MEDICATION NAME] and connections - adjust. -[MEDICATION NAME]. -Boom/arm pivot pins and bushings. -Scale display. -Front chasers. -Hand control. -Leg bolts. -Foot pedal. -Leg spreader pivot bar. -Mast/base bolts. -All casters clean. -Batteries. -Charger. -Lube pivot points on lift. -Check all external hardware and tighten if necessary. The above items had been checked on 12/13/17. Clips had not been monitored on the preventative maintenance record for lift 2. The lift was checked on 1/19/18, but clips had not been addressed on the record. Interview on 1/31/18 at 1:45 p.m. with the administrator, director of nursing, and quality assurance and performance improvement (QAPI) coordinator regarding the above incident revealed: The maintenance director was to do monthly preventative maintenance on the lifts. The administrator thought the clips had been broken after CNAs D and F began transferring resident 1. The QAPI coordinator had conducted interviews with CNAs D and F and was aware the clips had been broken prior to them using the lift for resident 1. Review of the provider's undated Mechanical Lift policy revealed maintenance was to service the lifts every six months or sooner if problems occurred. They were to keep a log of those services and maintain the records for five years. Review of the provider's undated Preventative Maintenance policy revealed: Preventative maintenance checklist to be completed by maintenance department with daily, monthly, quarterly, and annual tasks. Maintenance to keep checklist and initial and date those items when completed. The list includes but not limited to elevator policy, daycare door, and annual reports of smoke barrier condition and repair if needed. 2a. Observation and interview on 1/31/18 from 8:40 a.m. through 8:50 a.m. with CNAs A and B revealed: CNA A had been employed at the facility for three years. CNA B had been employed at the facility for one-and-a-half years. At 8:40 a.m. they went into resident 4's room to transfer her from her wheelchair to her bed. -They were using the total mechanical lift labeled 1. -They had a sling with four straps, but the lift had six hooks. -The lift was difficult to maneuver as the wheels had not moved easily. b. At 8:50 a.m. they went into resident 1's room to transfer her from her wheelchair to her bed. -They used the same lift but had a sling with six straps instead of just the four. The resident had a bruise under her right eye that was yellow and black. -CNA B stated that was from her fall out of the lift on 1/18/18. -When she fell she hit her head on the floor. -She thought the bruise was looking better. Neither CNA A or B had any training on the lifts since they started. c. Observation and interview on 1/31/18 at 8:55 a.m. with CNAs C and D regarding resident 5 revealed: CNA C had been employed at the facility for seven years. CNA D had been employed at the facility for sixteen years. They entered her room with the total mechanical lift labeled 2. They were transferring her from her wheelchair to her bed. The lift had four hooks. They were using a sling with six straps. They doubled up the straps in the front/leg hooks using the middle and bottom straps. -The head strap they hooked on the purple loop on the back/head hook. -The middle strap they hooked on the black loop on the front/leg hook. -The leg or lower strap they hooked the blue loop onto the front/leg hook. The lift had been hard to maneuver, and when asked about it CNA D stated You really have to put your back in it to get them to move. Only one resident that used the total mechanical lift had her own sling. CNA C and D were not sure if it mattered if they used the sling with 6 straps versus the sling with 4 straps. Neither CNA C or D had any training on the lifts since they had started at the facility. d. Review of the annual staff training records and agendas revealed they had not provided any training on proper use, sling selection, or maintenance of the lifts to any staff. There had not been any education after resident 1 had fallen out of the lift on 1/18/18 due to broken clips. Interview on 1/31/18 at 10:30 a.m. with the administrator revealed they had not provided any training on the mechanical lifts other then what the staff got when they started. They had not conducted any training after resident 1's fall on 1/18/18. Interview on 1/31/18 at 10:40 a.m. with the director of nursing and restorative aide [NAME] revealed: They had multiple, different sized slings that were used for multiple residents. Restorative aide [NAME] had been in charge of ordering new slings. She relied on the CNAs to inform her if new slings were needed and what size slings they needed. -They would guess the sling size based on the size of the resident. The CNAs had not been educated on correct sling sizes. They used different type slings with the mechanical lifts. They were unaware if the manufacturer's recommendations stated to use: -Four strap slings with six hook mechanical lifts. -Six strap slings with four hook mechanical lifts. Therapy had not been involved in determining appropriate sling sizes for the residents, and it had been left up to the CNAs to choose the size of sling.	2020-09-01
137	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-01-31	867	E	1	0	NOYG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, and policy review, the provider failed to identify concerns with multiple falls and to implement an effective performance improvement plan (PIP) and quality assurance program. Findings include: 1. Review of the provider's event summary report from 11/1/17 through 1/30/18 revealed there had been thirty-two falls involving sixteen residents. Interview on 1/31/18 at 12:25 p.m. with the quality assurance program nurse revealed: She had been in the role for about two years. She had received some training from the state quality assurance coordinator at the beginning. She was also the infection control nurse, the grievance official, and worked on the floor two days a week. -Today she had been scheduled to work in the office and not on the floor. Relevant to falls, she had taken over completing post fall huddle reports because CNAs and other staff were not completing them. -They had not looked at the data collected to determine staffing issues or environmental issues. -Interventions were implemented after the fall had occurred. -The falls PIP had been going on since (MONTH) (YEAR). Other PIP projects she was currently working on included: -Pressure ulcers - no date of initiation. -[MEDICATION NAME] screening - no date of initiation. -Food temperature recording was initiated in (MONTH) (YEAR). --She was unsure why the dietary manager was not involved with this PIP. -Perineal and catheter care was initiated in (MONTH) (YEAR). -Self-administration of medications was initiated in (MONTH) (YEAR). She had been in charge of all the above PIPs. Interview on 1/31/18 at 1:00 p.m. with the director of nursing revealed they had not had other department heads involved in the quality assurance PIP process. Review of the provider's undated Quality Assurance Performance Improvement policy revealed goals were to incorporate quality process assessment, evaluation, and improvement planning for all systems sustaining of improvement in quality within the organization.	2020-09-01
138	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	225	D	0	1	V4R811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to investigate and report one of one sampled resident's (16) fall with the use of a full-body lift to the South Dakota Department of Health (SD DOH). Findings include: 1. Review of resident 16's medical record revealed: She was admitted on [DATE]. She had current [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] -[MEDICAL CONDITION]. -[MEDICAL CONDITION], one eye. Her 8/12/17 quarterly Minimum Data Set assessment showed a Brief Interview for Mental Status score of fifteen indicating she was cognitively intact. Review of resident 16's 8/2/17 fall report revealed she: Was being transferred with the full-body lift. Was over the bed when the sling slipped off the lift, and she hit her head on the wall. Had a small raised area to the back of the left side of her head. Interview on 8/24/17 at 9:45 a.m. with the social services director revealed: She was not aware the incident needed to be reported to SD DOH since the resident did not have a major injury and was not sent to the hospital. There was no investigation to determine if there was a mechanical issue with the lift or if the resident was transferred incorrectly. Interview on 8/24/17 at 10:30 a.m. with the administrator revealed she acknowledged the incident had not been investigated and reported the SD DOH. Review of the provider's undated Abuse policy revealed, The investigative process includes a thorough assessment of the resident involved, interviews and observations with the resident, interviews with the staff members and interviews with the person involved .	2020-09-01
139	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	279	D	0	1	V4R811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to develop a comprehensive care plan based on the individual residents' care areas for three of nine sampled residents (4, 6, and 7). Findings include: 1. Review of resident 7's 9/28/16 annual Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) revealed: Her Brief Interview for Mental Status (BIMS) score was nine indicating her cognition was moderately impaired. She had an unplanned weight loss. The following CAAs were triggered: -Cognition loss. -ADL function/rehabilitation (rehab) potential. -Urinary incontinence/catheter. -Falls. -Nutritional status. -Dental care. -Pressure ulcers. Review of resident 7's weight records revealed from 6/13/17 through 6/26/17 she had an eleven pound weight loss. Observation and interview on 8/22/17 at 2:00 p.m. with resident 7 revealed she was sitting in a wheelchair in her room. She had been drinking a pink drink and when asked what it was she stated They want me to drink it because of my weight. Review of resident 7's 7/12/17 care plan revealed nutritional status and pressure ulcers had not been addressed on the care plan. There were no interventions listed for the resident's weight loss. 2. Review of resident 6's 11/14/16 annual MDS assessment and CAAs revealed: Her BIMS score was nine indicating her cognition was moderately impaired. She used tobacco. The following CAAs were triggered: -[MEDICAL CONDITION]. -Cognition loss. -Communication. -ADL function/rehab potential. -Urinary Incontinence/catheter. -Mood state. -Falls. -Nutritional status. -Dental care. -Pressure ulcers. Observation and interview on 8/22/17 at 4:35 p.m. with resident 6 revealed: She had been outside in the smoking area smoking a cigarette. She was not wearing an apron. Two of her daughters resided in the facility. One of the daughters held her cigarettes and lighter for her. That was her last cigarette, and her daughter was out of the facility getting her more. Review of resident 6's 7/7/17 Safe Smoking Evaluation revealed the smoking materials were to be secured by staff. Review of resident 6's 6/21/17 care plan revealed communication, mood state, falls, nutritional status, pressure ulcers, and smoking had not been addressed on the care plan. 3. Review of resident 4's 4/2/17 annual MDS assessment and CAAs revealed: Her BIMS score was a three indicating her cognition was severely impaired. The following CAAs were triggered: -[MEDICAL CONDITION]. -Cognition loss. -Visual function. -Communication. -Urinary incontinence/catheter. -Falls. -Pressure ulcers. -[MEDICAL CONDITION] drug use. Observation and interview on 8/22/17 at 2:30 p.m. with resident 4 and her daughter revealed: The resident was sitting in her wheelchair. She was unable to answer questions from this surveyor. Her daughter stated she had a fall a few months back and was now in the wheelchair more often. Interview on 8/23/17 at 2:45 p.m. with the MDS coordinator revealed resident 4 had a fall on 4/10/17 with bruising. They had not updated the care plan with interventions after the fall. Review of resident 4's 7/6/17 care plan revealed visual function, falls, and pressure ulcers had not been addressed on the care plan. 4. Interview on 8/24/17 at 9:30 a.m. with the director of nursing regarding the care plans for residents 4, 6, and 7 revealed: Resident 7's weight loss should have been care planned along with the other CAAs triggered. The smoking materials for resident 6 should have been kept by the staff, but she had been noncompliant. -She agreed that should have been care planned along with the other CAAs triggered. Fall interventions for resident 4 should have been care planned along with the other CAAs triggered. Review of the provider's undated care plan policy revealed: A comprehensive care plan should have been developed for each resident. The care plan should have included measurable goals. All staff were responsible for keeping the care plan updated with current information.	2020-09-01
140	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	315	E	0	1	V4R811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the provider failed to prevent the reoccurrence of urinary tract infections [MEDICAL CONDITION] for two of two sampled residents (8 and 9) with a catheter by ensuring: Personal care was provided as per care plan or as provider's policy. Drainage bags were kept in a position to promote urine flow by gravity. Findings include: 1. Review of resident 8's complete medical record revealed: She was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Her current care plan stated: -To check and change her brief every two hours and as needed. -To provide incontinence care after an incontinence episode. -Position foley catheter bag below the bladder. She was always incontinent of stool due to her MS and often had smears with peri-care. She leaked urine around her catheter tubing. Her certified nursing assistant (CNA) flow sheet did not mention catheter care. Observation on 8/22/17 at 12:45 p.m. with resident 8 revealed: CNA [NAME] emptied her foley catheter drainage bag and did not use an alcohol swab to clean the spout. Her foley catheter bag had been hanging on the footboard of the bed above her bladder. LPN G changed her adult brief, and she had a small bowel movement. No peri-care or catheter care was done. LPN G wiped her anal area. Observation on 8/23/17 at 9:20 a.m. with resident 8 revealed: LPN G had changed her coccyx dressing. The foley catheter bag had laid on the end of the bed, even with her bladder. Staff had left the room with the bag laying on the end of the bed between the resident's legs. Observation on 8/23/17 at 2:00 p.m. and at 3:30 p.m. with resident 8 revealed the foley catheter bag had been laid at the end of her bed between her legs. Observation and interview on 8/24/17 at 9:05 a.m. in resident 8's room with CNA F revealed she: Had emptied the urine out of the drainage bag. Had not used an alcohol swab to clean the end of the spout. Stated the resident's adult brief was dry. Had been hired in (MONTH) (YEAR). Stated the resident's catheter bag had always hung at the end of the bed, on the footboard, in a black drainage bag cover. Was not instructed to use an alcohol swab when emptying urine out of the drainage bag. Could not find alcohol wipes stored in the resident's room. Observation and interview on 8/24/17 at 9:20 a.m. in resident 8's room revealed: LPN G had changed the dressing on her coccyx wound. LPN G and CNA F were getting her adult brief and pants pulled up. When asked by this surveyor if her brief had been wet they took off her pants again and changed her brief. The brief was wet. No peri-care was done. Observation and interview on 8/24/17 at 9:45 a.m. of resident 9 revealed: The drainage bag was hanging on the footboard of her bed. -The tubing was threaded through her pant leg. CNA H stated: -She had emptied her drainage bag every two hours. -Her drainage bag would have hung on the end of the bed, on the top of the footboard, in the black drainage bag cover. -The tubing and the bag was higher than the resident's bladder. Interview and observation on 8/24/17 at 3:40p.m. of LPN G in resident 8's room revealed: She stated the foley catheter bag usually hung on the end of the bed on the foot board. She stated it was probably a little below the bladder. She agreed that it probably was not low enough. The tubing was threaded through the resident's pant leg. Her physician did not test for UTIs or treat them anymore, because she always had one. The tubing was not long enough to hang below her bladder level. 2. Review of resident 9's complete medical record revealed: Her [DIAGNOSES REDACTED]. She had been hospitalized in (MONTH) (YEAR) for a UTI that had grown out Pseudomonas. -She was lethargic. Family had mentioned to the physician that her foley catheter bag was not always BEING IN A DEPENDENT POSITION-ESPECIALLY WITH TRANSFERS. -The physician had written the above in her progress notes on 6/30/17. On 6/23/17 her physician had ordered Foley catheter care every shift, three times daily. Her care plan directs foley catheter care with every shift, three times daily. Foley catheter care was not documented thirty-three out of sixty-nine shifts in (MONTH) (YEAR) on the resident's CNA flow sheet. Observation on 8/22/17 at 8:15 a.m. with resident 9 revealed her Foley catheter bag had been laid at the end of her bed between her legs. Observation on 8/23/17 at 8:00 a.m. with resident 9 revealed her catheter bag had been laid at the end of her bed between her legs. Interview on 8/23/17 at 4:20 p.m. with CNA L revealed: The residents received peri-care in the morning and before bed. Usually did not have any care during the day with resident's with catheters. Review of the provider's undated Perineal Care policy revealed the nursing staff would have provided perineal care to residents twice daily and after each incontinence episode. Review of the provider's undated Care of Indwelling and Suprapubic Catheters revealed: The catheter tubing must have been placed so the urine could flow unobstructed. They were to ensure that the tubing had been above the level of the drainage bag. The drainage bag must have always stayed lower than the bladder to prevent back flow of urine into the bladder. Use an alcohol swab to cleanse the spout after having drained the bag. Cleanse around the catheter insertion area daily and at each brief change. Thoroughly cleanse the perineum after all bowel movements to prevent infection.	2020-09-01
141	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	323	D	0	1	V4R811	Based on observation, record review, and interview, the provider failed to appropriately assess one of one sampled resident (12) who attempted to exit the facility. Findings include: 1. Observation on 8/22/17 from 4:30 p.m. through 5:20 p.m. of the front door revealed: At 4:30 p.m. the alarm had been not sounding. Visitors had been walking in and out of the building through that door. The receptionist had been sitting at the desk looking down. At 4:50 p.m. resident 12 walked out the front door and stood on the sidewalk. -She turned and came back inside. At 5:01 p.m. resident 12 went to the front door again where two visitors redirected her to the chair. At 5:09 p.m. she went to the front door again. -Licensed practical nurse (LPN) L asked an unidentified CNA to redirect resident 12 from the front door. Resident 12 said she was waiting for someone and did not want to miss them. At 5:11 p.m. LPN L reset the door alarm system, and the alarm sounded again. Interview on 8/22/17 at 5:25 p.m. with LPN L regarding resident 12 revealed: The resident was confused. She thought she was waiting for someone, but there was no one coming for her. The resident would go outside by herself sometimes and sit on the bench. She did not have a Wanderguard on her. Review of resident 12's 6/8/17 Minimum Data Set assessment revealed she had a Brief Interview for Mental Status score of three indicating her cognition was severely impaired. She ambulated on her own with a walker. Review of resident 12's 6/8/17 Elopement Risk assessment revealed she was at low risk for leaving the facility. Interview on 8/23/17 at 1:45 p.m. with the maintenance supervisor regarding the front door revealed: There were two buttons to turn off the system. One button acknowledged the person walking in the door. -The alarm would be silenced until it was reset. -The lights behind the nursing station would stay on. *The second button would reset the alarm, so it sounded anytime a person walked in or out of the building. Interview on 8/24/17 at 9:00 a.m. with the administrator regarding resident 12 revealed she would go outside on her own and sit on the bench. She agreed she was confused. Interview on 8/24/17 at 9:30 a.m. with the director of nursing regarding resident 12 revealed she agreed the resident was confused. She should have been assessed for a Wanderguard. A plan should have been in place for her when she went outside and sat on the bench.	2020-09-01
142	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	371	D	0	1	V4R811	Based on observation, interview, and policy review, the provider failed to ensure the recording of food temperatures in one of two kitchen observations. Findings include: 1. Observation on 8/22/17 at 8:00 a.m. during the initial walk through tour of the kitchen revealed: A Food Temperature Monitor log in the kitchen. -Had been dated from 5/17/17 to 8/18/17. -Had several meals and dates missing. -Had no temperatures recorded after 8/18/17. Interview on 8/22/17 at 8:10 a.m. with cook A revealed he: Had checked the breakfast food temperatures. Had not recorded them on the log. Forgot to record food temperatures frequently. Interview on 8/22/17 at 12:30 p.m. with cook B revealed she: Had checked the lunch food temperatures. Forgot to record food temperatures frequently. Interview on 8/24/17 at 9:30 a.m. with the dietary manager revealed she: Had always checked food temperatures when she was cooking. Forgot to record food temperatures frequently. *Had the expectation that all food temperatures were to be checked and recorded at each meal. Interview on 8/24/17 at 12:45 p.m. with the administrator revealed she had the expectation that all food temperatures were to be checked and recorded at each meal. Review of the provider's undated Food Temperatures policy revealed Take temperatures often to monitor for safe food holding temperature ranges of at or below 41 degrees F for cold foods; and at or above 135 degrees F for hot foods.	2020-09-01
143	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	554	E	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure steps had been completed to support appropriate self-administration of medications for five of five residents (3, 20, 22, 26, and 40) who self-administered their medications. Findings include: 1. Observation on 10/31/18 at 10:40 a.m. of unlicensed assistive personnel (UAP) B during a nebulizer medication administration for resident 22 as she sat upright in her chair revealed the UAP: Poured the [MEDICATION NAME] inhalation medication into the chamber of the nebulizer. Called the resident's name until she opened her eyes. Attached the nebulizer mask around the resident's face. Turned on the machine. Said she would return to the resident's room in ten to fifteen minutes when the nebulizer medication was finished. UAP B was asked at this time if the resident was capable of keeping the medication mask on for the full treatment, and if she would know if the resident had received all of the medication. The UAP replied: Resident 22 slept most of the time. Sometimes she removed the mask and shut the machine off herself. When that happened she would reapply the mask and start the machine again. Residents were assessed for their ability to self-administer medications. -She did not know if there was documentation of their ability to self-administer those medications. The medication administration record (MAR) had not indicated if this resident was able to self-administer medications. At 11:10 a.m. UAP B reentered resident 22's room and stated: The resident had removed the mask herself while she was out of her room. There was still some medication left in the nebulizer chamber. She would wake the resident and reapply the mask until the medication was gone. She was not sure if the other UAPs or nurses had completed the nebulized medication when the resident had removed her mask. Review of resident 22's medical record revealed: She was admitted on [DATE]. A 2/8/18 physician's order for [MEDICATION NAME] nebulizer twice daily. No physician's order for the resident to self-administer the [MEDICATION NAME]. The 10/1/18 through 10/31/18 MAR had not indicated the resident was to have self-administered the [MEDICATION NAME]. No medication self-administration evaluation or assessment. The revised 9/21/18 care plan: -Had indicated Administer neb treatments as ordered. -Had not indicated the resident was to have self-administered the [MEDICATION NAME] after nursing set-up. The 9/12/18 Minimum Data Set (MDS) assessment indicated her Brief Interview for Mental Status (BIMS) score was six, indicating she had severe cognitive impairment. 2. Review of resident 40's medical record revealed: He was admitted on [DATE]. The most recent (10/19/18) physician's orders report had included orders for: -[MEDICATION NAME] nebulizer twice daily. -Pulmacort nebulizer twice daily. No physician's orders to self-administer the above nebulized medications. A 10/19/18 physician's order for Halls cough drops as needed. -May have at bedside. A 10/13/18 physician's order for Icy Hot stick for joint pain. -May have at bedside. Review of the 10/1/18 through 10/31/18 MAR revealed:No indication the nebulizer treatments were to have been self-administered. No documentation regarding: -The dates or times the Icy Hot had been used. -No medication count of how much was used or what was left in the locked box. The Halls cough drop order: -Had not been transcribed on the MAR. -There was no documentation regarding: --The dates or times the cough drops had been used. --No medication count of how much was used or what was left in the locked box. Further review of the medical record revealed: No medication self-administration evaluation or assessment was completed for the above medications. The revised 7/24/18 care plan: -Had no indication the Icy Hot or cough drops were to have been self-administered. -Had documentation for self-administration of the nebulizer treatments. The 10/18/18 MDS assessment indicated her BIMS score was six, indicating severe cognitive impairment. 3. Review of resident 26's medical record revealed: He was admitted on [DATE]. A 9/19/18 MDS BIMS score of thirteen indicating his cognition was intact. The following physician's orders in the 10/1/18 through 10/31/18 physician's order report included: -1/4/17: Muscle Rub cream. (MONTH) have for in room use. -7/11/18: [MEDICATION NAME] eye drops, one drop as needed. --The order had not indicated which eye the medication was to have been administered into. --May keep in room and administer per self. Further review of the medical record revealed: A care conference was held on 9/12/18. At that time it was decided the self-administration of muscle rub was not appropriate. A 9/12/18 evaluation signed by the interdisciplinary team (IDT) indicated the resident was to have been assessed often as His mental status is known to fluctuate. -The evaluation was completed weekly since the initial evaluation had been completed on 9/12/18. Review of the 10/1/18 through 10/31/18 MAR revealed:Neither the muscle rub nor the [MEDICATION NAME] eye drops had been transcribed onto the MAR. There was nothing on the MAR to indicate: -The dates or times the above medications had been used. -A medication count of how much of the [MEDICATION NAME] was used or what was left in the locked box. Review of resident 26's care plan revealed a 5/10/16 approach: [MEDICATION NAME] eye drops for in room use. Monthly In-room medication assessments done. 4. Review of resident 3's medical record revealed: He was admitted on [DATE]. A 9/1/18 BIMS score of fifteen indicating his cognition was intact. The following physician's orders: -On 6/2/14: HFA aerosol inhaler twice daily as needed. (MONTH) keep at bedside. -On 5/19/16: Saline nasal mist to have been used as needed; (MONTH) keep at bedside. -On 9/11/18: Rolaids Advance Plus Anti-gas Chewable tablets twice daily as needed; (MONTH) have in room. -On 9/11/18: Max Freeze cream twice daily as needed; (MONTH) have in room. None of the above orders had indicated the resident could self-administer those medications. A medication self-administration evaluation and assessment: -Had been completed on 9/12/18. -Indicated Resident does well. Will do quarterly evals. The 9/7/18 medication care plan revealed: -Resident has in room medications for his use. -Resident will have the following meds at bedside: Saline nasal mist, TUMS, Bentolin HFA inhaler. -The Max Freeze cream had not been included in the care plan. Review of his 10/1/18 through 10/31/18 MAR: -Had not contained transcribed physician's orders for any of the above medications. -Had no documentation to indicate: --The dates or times the above medications had been used. --A medication count of how much of the medications were used or what was left in the resident's room. 5. Review of resident 20's medical record revealed:She was admitted on [DATE]. A 9/5/18 BIMS score of seven, indicating severe cognitive impairment. A 10/19/18 physician's order for Halls cough drops as needed; (MONTH) have at bedside. A 10/20/18 medication self-administration assessment had been completed. The evaluation indicated:-Has been informed on proper in room use of medication. -The nursing staff would monitor and do a quarterly assessment. Review of her 6/11/18 care plan indicated: She had memory problems related to a dementia diagnosis. No documentation regarding the cough drops or self-administration of medication. Review of her 10/1/18 through 10/31/18 MAR: Had not contained transcribed physician's orders for the cough drops. Had no documentation to indicate: -The dates or times the above medications had been used. -A medication count of how much of the medications were used or what was left in the resident's room. 6. Interview on 10/31/18 at 2:00 p.m. with the Minimum Data Set (MDS) coordinator regarding resident 22's nebulizer medication observation and self-administration of medications revealed: Residents are assessed for their ability to keep medications in their rooms and self-administration of those medications. There were two residents (22 and 40) who self-administered their nebulizer medications after the nurse set the medication up and applied the mask. -Those residents were not assessed for their ability to self-administer medications. There were four residents (3, 20, 26, and 40) who kept medications in their rooms in a locked box or drawer. -Those four residents were assessed for their ability to self-administer medications. Interview on 10/31/18 at 4:30 p.m. with the MDS coordinator and the director of nursing confirmed they had not followed their policy for self-administration of medications. Review of the provider's undated Self-Medication Administration Program policy revealed: Residents who were competent the opportunity to self-administer their own medication would be allowed to do so. Goal: The resident would take the medication at bedside safely using proper dosage, order, technique, and storage of the medication. Procedure had included: -A conference with the resident, medication nurse or unlicensed assistive personnel (UAP), the director of nursing, and any other staff. -If it was determined the resident was a candidate for medication self-administration the physician would be contacted for an approval and orders. -If it was determined the resident was not able to safely participate in the program the physician would have been notified of the evaluation results leaving the final decision to the resident's primary physician. -A physician's order was to have included the medication the resident could keep at the bedside, dose, time, and further instructions as needed. -The resident's care plan was to have included information regarding the self-administration of medications. -Medications were to have been kept in a locked container. -A monthly medication count was to have been completed and documented on the MAR by the medication nurse or UAP. -The resident needed to be responsible to record on a MAR: --The days the medication was taken or applied by self or the nursing staff. --The time the medication was taken if appropriate. -The resident would receive a new documentation form at the beginning of each month. -The medication at the bedside was to have been addressed and evaluated at the resident's care conference or at least quarterly or if there was a change in the resident's condition.	2020-09-01
144	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	637	D	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and Resident Assessment Instrument (RAI) manual review, the provider failed to complete a significant change of condition Minimum Data Set (MDS) assessment for one of one sampled resident (42) who required more physical assistance. Findings include: 1. Random observations on 10/30/18 from 8:00 a.m. through 5:30 p.m. and 10/31/18 from 8:00 a.m. through 4:00 p.m. of resident 42 revealed: She spent most of her time alone and on her bed. She had little interaction with staff or other residents. Interview on 10/30/18 at 2:30 p.m. with the MDS coordinator regarding resident 42 revealed: She had been feeling sick for the last few weeks. The physician had increased her anxiety medication on 10/2/18, because she was restless and had exhibited increased physical and verbal aggression. The physician discontinued the medication on 10/17/18 when physical changes were noted. She had continued to exhibit declines in her abilities. Review of resident 42's medical record revealed: She was admitted on [DATE]. [DIAGNOSES REDACTED]. On 10/2/18 her physician had increased her [MEDICATION NAME] due to increased restlessness and anxiety. On 10/10/18 she was found on the floor, and no injury was identified. After this event: Physical therapy was ordered, but the resident refused to be evaluated. Her [MEDICATION NAME] was discontinued on 10/17/18 due to increased sedation and confusion. [MEDICATION NAME] was ordered 10/17/18 after the nurse noted some respiratory concerns. Review of her quarterly 7/26/18 MDS assessment revealed: In section C her Brief Interview for Mental Status (BIMS) score was three indicating she had severe cognitive impairment. In section D, mood severity she: -Exhibited feeling tired two to six days a week. In section E, behaviors she: -Exhibited physical and verbal aggression one to three days a week. -Wandered one to three days a week. In section G, activities of daily living (ADL) she: -Was able to reposition herself in bed, transfer, and walk independently. -Dressed with extensive assistance of one staff member. -Toileted independently. -Ate independently after set-up assistance. -Performed hygiene independently. Review of her quarterly 10/21/18 MDS assessment revealed: In section C her BIMS score remained at three, indicating severe cognitive impairment. In section D she: -Exhibited feeling tired two to six days a week. -Exhibited trouble concentrating two to six days a week. -Exhibited slowed movements or speech two to six days a week. In section [NAME] she: -Did not exhibit physical or verbal aggression. -Did not exhibit wandering behaviors. In section G she: -Required set-up assistance by staff with repositioning herself in bed, transfers, and walking. -Dressed with extensive assistance of one staff member. -Required extensive physical assistance with toileting. -Ate with supervision and set-up assistance. -Required extensive physical assistance with her hygiene. Interview on 10/31/18 at 4:30 p.m. with the MDS coordinator and the director of nursing regarding resident 42's ADL declines revealed: The resident had exhibited declines with her ADL assistance and her mood. The MDS coordinator had completed a scheduled quarterly MDS assessment on 10/21/18. -She had not completed a comprehensive significant change in status assessment. The MDS coordinator stated she should have completed the significant change assessment at that time. The provider used the RAI manual as a policy for completing the MDS assessment. Review of the (MONTH) (YEAR), Version 1.16 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed:Page 2-22: A significant change was a decline or improvement in a resident's status that: -Would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. -Impacted more than one area of the resident's health status. -Required interdisciplinary review and/or revisions of the care plan. Page 2-25: A significant change in status assessment (SCSA) was appropriate if there were either two or more areas of decline. A decline in two or more of the following had included: -Presence of a resident mood item not previously reported, such as an increase in the number of areas where behavioral symptoms were coded. -Any decline in a ADL physical functioning area where a resident is newly coded as extensive assistance. Page 2-32: If the significant change in status was identified in the process of completing any assessment, the assessment was to have been completed as a SCSA and completed as a comprehensive assessment.	2020-09-01
145	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	686	D	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure one of three sampled residents (33) who had developed a pressure ulcer while in the facility had ongoing assessments, wound documentation, care planning, and appropriate dietary interventions. Findings include: 1. Observation and interview on 10/30/18 at 10:18 a.m. in resident 33's room with certified nursing assistants (CNA) C and D revealed they were going to transfer her with the mechanical lift from the wheel chair into the bed. Following the transfer they were going to check her for incontinence and do perineal (peri)-care. Before continuing with the transfer the surveyor had asked the residents permission to remain in the room to observe. She declined so the surveyor exited the room prior to the transfer. Observation and interview on 10/31/18 at 9:22 a.m. in resident 33's room with two CNAs revealed they were going to transfer her with the mechanical lift from the wheel chair into the bed. Following the transfer they were going to check her for incontinence and do peri-care. Before continuing with the transfer the surveyor had asked the residents permission to remain in the room to observe. She declined so the surveyor exited the room prior to the transfer. Review of resident 33's medical record revealed the following nursing progress notes: On 10/8/18 at 4:43 a.m.: During personal cares resident was noted to have 2 red areas to the top, middle area of her buttocks, large one measures 3 cm (centimeter) x 1.5 cm, the smaller one measures 1 cm x 1 cm. No open areas noted. On 10/8/18 at 3:17 p.m.: (Physician name) notified of 2 reddened areas to coccyx. Telephone order received to apply Bag Balm topically to buttocks with each brief change. On 10/23/18 at 3:34 p.m.: Assessed resident's buttocks today. There are no red areas and no open areas at this time. There was no documentation the certified dietary manager (CDM) or registered dietitian (RD) had been notified of her pressure ulcer. Review of the 10/9/18 physician order [REDACTED]. Every Shift. Review of resident 33's annual 10/3/18 Minimum Data Set (MDS) assessment revealed: A Brief Interview for Mental Status examination score of seven indicating cognitive impairment. It had not been coded as having physical, verbal, or other behavioral symptoms. She required extensive assistance of two staff with bed mobility, toilet use, and personal hygiene. She required total assistance with a mechanical lift and two staff assistance with transfer. She was always incontinent of bladder and frequently incontinent of bowel. She was on a therapeutic diet. She had been coded as not at risk for developing pressure ulcers/injuries. Skin conditions had been coded as pressure reducing device for chair and bed, and nutrition or hydration interventions. The undated Braden scale for determining pressure ulcer/injuries had a score of eighteen indicating she was at risk. Review of the (MONTH) (YEAR) Treatment Assessment Record (TAR) did not have documentation for the Bag Balm treatment. Review of the 10/8/18 skin assessment record revealed there had not been any documentation completed for the identified area. Review of the current care plan revealed there had been no documentation she had been identified as being at risk or having a pressure ulcer, no goals, or approaches. Interview on 10/31/18 at 9:27 a.m. with licensed practical nurse A regarding the physician's orders [REDACTED]. The order had not been documented on her TAR. It should have been documented on it. Interview on 10/31/18 at 11:20 a.m. with the MDS registered nurse regarding resident 33 revealed: The skin documentation had not been completed. No further skin documentation had been completed. Dietary had not been notified of the pressure area. There was no documentation related to skin issues on the care plan. Bag Balm should have been documented on the TAR. When a pressure ulcer was discovered the nurse on duty was: -Expected to assess, measure, and complete the pressure ulcer stasis injury event report. -Pass the information on in report. -Update the physician. -Update the CDM. Pressure ulcers were to be monitored weekly. The care plan was updated by the MDS registered nurse. She felt the process for pressure ulcers was not completed as it should have been. Interview on 10/31/18 at 1:57 p.m. with the director of nursing regarding resident 33's pressure ulcer revealed: There should have been a skin assessment documentation completed. Her expectations would have been for:-Dietary and the RD to have been notified in case they wanted to order a supplement. -The Bag Balm treatment should have been listed on the TAR. -The skin/wound nurse should have been notified. -The care plan should have addressed the issue with skin even if they were at risk or had a history of [REDACTED]. They had not followed their Pressure Ulcer/Impaired Skin policy. Interview on 10/31/18 at 2:51 p.m. with the CDM regarding the pressure ulcer for resident 33 revealed: She had not been notified of the pressure ulcer. Her process once notified of any resident with skin issues was to contact the RD immediately either by calling or email. The RD would respond in a timely manner with her recommendations for the resident. Review of the (MONTH) (YEAR) Pressure Ulcer/Impaired Skin policy revealed: If resident should obtain a pressure ulcer follow these steps: -The nurse on duty when pressure ulcer/impaired skin integrity is discovered will perform an assessment. -Assessment includes measurement of area affected. -Nurse will then notify MD with assessment and follow recommendations/orders given. -Documentation of the pressure ulcer/impaired skin integrity to be done in a Matrix Event or in progress note. -Notify dietary department of wound. -Pressure ulcers will be followed and assessed weekly by designee. -Observations will then be completed until area is healed. -MDS coordinator to be notified of Pressure ulcer/impaired skin integrity -MDS will be updated accordingly. Review of the provider's (MONTH) (YEAR) Care Plans policy revealed: A comprehensive care plan will be developed for each resident. The care plan must include measurable goals and time tables to meets a resident's medical, nursing, and psychological needs as identified in the assessment. The care plan will be completed by the Resident Assessment Coordinator. The multi disciplinary team will be responsible for adding new problems, treatments, and interventions. It is the responsibility of all staff to keep it updated with current information and changes in the plan of care and goals.	2020-09-01
146	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	698	D	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow professional standards for one of one sampled resident (1) who received [MEDICAL TREATMENT] at an off-site facility including: Assessment of resident before and after [MEDICAL TREATMENT] treatment. Ongoing communication between the [MEDICAL TREATMENT] facility and the provider. Findings include: 1. Observation on 10/31/18 at 8:17 a.m. revealed resident 1 had left for her scheduled [MEDICAL TREATMENT] treatment at an off-site [MEDICAL TREATMENT] facility. Review of resident 1's medical record revealed: She received [MEDICAL TREATMENT] at an off-site [MEDICAL TREATMENT] facility on Mondays, Wednesdays, and Fridays. No documentation was found regarding: -Her vital signs and health status before or after [MEDICAL TREATMENT] treatments. -If she had been monitored for [MEDICAL TREATMENT] related complications such as bleeding, [MEDICAL CONDITION], or excess fluid. -Communication between the [MEDICAL TREATMENT] facility and the provider before or after [MEDICAL TREATMENT] of her vital signs, weights, health status, or treatment provided. Review of the provider's 6/9/16 [MEDICAL TREATMENT] and Fistula Intervention Policy and Procedure revealed: On resident's arrival back to the facility (provider) from [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) facility, resident should arrive with [MEDICAL TREATMENT] Communication Form or the [MEDICAL CONDITION] facility should fax back to LTC (long term care) facility. Observation and interview on 10/31/18 at 1:02 p.m. with resident 1 regarding her [MEDICAL TREATMENT] routine revealed she: Had returned from her scheduled [MEDICAL TREATMENT] treatment. Had [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays. Stated she did not take any papers with her to the [MEDICAL TREATMENT] facility and they did not send any papers back with her. Interview on 10/31/18 at 2:53 p.m. with the director of nursing (DON) regarding resident 1 and their above policy revealed: They were to have used [MEDICAL TREATMENT] Communication forms. -None were found in her record. No documentation was found regarding: -Her vitals and health status before or after [MEDICAL TREATMENT] treatments. -If she had been monitored for [MEDICAL TREATMENT] related complications such as bleeding, [MEDICAL CONDITION], or excess fluid. -Communication between the [MEDICAL TREATMENT] facility and the provider before or after [MEDICAL TREATMENT] of her vitals, weights, health status, or treatment provided. She would have expected documentation of: -Communication between the [MEDICAL TREATMENT] center and the provider. -Vitals and health status before and after [MEDICAL TREATMENT] treatments. -Assessment for [MEDICAL TREATMENT] related complications. Interview on 10/31/18 at 3:31 p.m. with the DON and the Minimum Data Set assessment coordinator regarding the above findings revealed: They had not utilized the [MEDICAL TREATMENT] Communication forms. They had requested documentation from the [MEDICAL TREATMENT] facility on 10/31/18. It had not been received at the time of the interview.	2020-09-01
147	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	761	E	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to have a system in place to maintain the security of biohazards such as used syringes and narcotic [MEDICATION NAME]es in sharps containers that were ready for destruction in two of two unsecured soiled utility rooms (north and east) and one of one unsecured biohazard room. Findings include: Surveyor 1. Observation on 10/30/18 at 4:15 p.m. in the basement was an unlocked door with a sign on it marked Biohazard. The unlocked door led into a room that had two boxes on the floor. Inside of the boxes were items in red biohazard bags. Surveyor Observation on 10/31/18 at 2:00 p.m. with licensed practical nurse (LPN) A of the north medication (med) room and north med cart revealed sharps containers on the med room wall and med cart were attached to the wall or cart. Interview with LPN A at that time regarding the sharps containers revealed when the containers were full: The nurse: -Used a key to remove the sharps containers from the med cart or med room wall. -Closed the lid of the plastic container. -Brought the full container to the soiled utility room. -Placed the container in a cardboard biohazard box. When the biohazard box was full someone would remove the box from the soiled utility room and transferred it to the biohazard room in the basement. She was not sure who brought the biohazard box to the biohazard room. She confirmed: -The soiled utility rooms were not locked. -All staff had access to the sharps containers in the soiled utility rooms. When asked if nurses placed any medications into the sharps containers she stated: -Medications up for disposition were supposed to have been destroyed. -Medications should not have been placed in sharps containers. -She did not place used medication vials in sharps containers. When questioned what the provider's policy was for destroying [MEDICATION NAME] narcotic patches she stated: -She was not sure what the policy was. -She destroyed used patches by flushing them in the toilet. -She was not sure what the other nurses did. Observation of a closed sharps container in a biohazard box in the north soiled utility room revealed an unidentifiable medication vial. LPN A confirmed the medication vial should not have been placed in the sharps container. Interview on 10/31/18 at 4:45 p.m. with the director of nursing and the Minimum Data Set coordinator regarding sharps storage confirmed: The soiled utility rooms were not secured. All employees had access to those sharps containers awaiting destruction in the soiled utility rooms. Medications were not to have been disposed of in sharps containers. The biohazard storage room in the basement was always locked. The elevator was used to get to the basement. -That elevator required a key code for access. -That code was the same code used to access other areas, including the front door. -All employees used that code to get access to the basement. Observation on 10/31/18 at 5:00 p.m. of the biohazard storage room in the basement revealed: The door was unlocked. Two cardboard biohazard boxes approximately eighteen by twenty-four inches wide by two and one-half feet tall. One box was full of sharps containers. One box was three-quarters full of sharps containers. Review of the provider's undated Sharps Container Destruction policy revealed: When the sharps containers were full the cover was to have been sealed with the container cover. That container was to have been placed in a biohazard box in the north wing or east wing soiled utility room. When the biohazard boxes were full the maintenance employees would remove the box from the utility rooms and take them to the biohazard room. All biohazard material is to be kept locked up until pick up. Review of the provider's undated Narcotic Destruction policy revealed: Narcotics were to have remained in the double-locked box and have been counted each shift until the consultant pharmacist destroyed them with the nurse on duty. *[MEDICATION NAME]es that were removed from a resident were to have been destroyed by placing them in the sharps container.	2020-09-01
148	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	880	E	0	1	1P5611	Based on observation, interview, and policy review, the provider failed to ensure infection control practices were maintained for: One of one observed bed making, clean linen cart so it was not cross-contaminated with soiled linens. One of four dryer drum windows that had a cleanable surface Four of four randomly observed residents' rooms (215, 217, 218, and 221) that had rusted side rails. Hand hygiene between residents' rooms by one of one housekeeper (G). Findings include: 1. Observation and interview on 10/30/18 at 9:10 a.m. in the east hallway revealed: A linen cart with a large rip on the top right hand corner cover. On the left middle section of that cart was a plastic bag with soiled cloths in it. Interview at that time with housekeeper [NAME] regarding the cart revealed: She used the cart for changing bed linens. The cart contained clean sheets, blankets, and soaker pads. She used the cloths to clean the beds and wipe the walls and door frames. She discarded the soiled cloths into the plastic bag attached to the linen cart. Interview on 10/31/18 at 8:25 a.m. with the head of housekeeping regarding the above linen cart revealed the soiled cloths should not have been stored on the clean linen cart. Surveyor 2. Observation on 10/30/18 at 9:00 a.m. of the 200 wing and on 10/31/18 at 3:30 p.m. confirmed four private residents' rooms 215, 217, 218, and 221 contained beds with half side rails on each side at the head of the beds. All of those side rails had chipped paint and rusted areas. Interviews on 10/31/18 at 4:30 p.m. with the director of nursing (DON) and again at 5:10 p.m. with the administrator revealed: The DON was aware of the poor condition of the side rails. The administrator was not aware of the rusted areas on the side rails. Both the DON and the administrator confirmed the rusted areas were not washable surfaces and created an infection control hazard. The maintenance supervisor was not available for interview. Surveyor 3. Observation and interview on 10/30/18 at 10:26 a.m. in the basement laundry area with laundry aide F revealed: Dryer number one had a 1.5 inch by 0.25 inch opened area in the front top area of the dryer drum window. Surrounding the dryer drum window were eight pieces of black duct tape applied to the outer section around the window drum cover. Interview at that time with laundry aide F regarding the dryer drum window revealed: The dryer drum window had been broken before. It had been awhile since it had been fixed. She had not notified the maintenance director about the broken dryer drum window, and that was her responsibility. The dryer drum window had not been cleanable due to the above. Interview on 10/31/18 at 8:20 a.m. with the maintenance director regarding environmental problems revealed: He had been working at the facility for two months. A lot of his time had been spent fixing plumbing and lights. He had been unaware of a broken dryer drum window cover for dryer number one. He had been informed of it yesterday. He had been busy checking out all the areas in the facility. He had not implemented a preventative maintenance program. He had been using the former maintenance directors list for fixing items. 4. Observation and interview on 10/30/18 from 10:52 a.m. through 10:56 a.m. with housekeeper G regarding the cleaning of residents' rooms revealed: She had come out of a resident's room with a pair of gloves on. She stated she: -Usually wore gloves when cleaning residents' rooms. -Changed her gloves every few rooms and used hand gel. 5. Interview on 10/31/18 at 11:06 a.m. with the infection control registered nurse regarding the above observations revealed: The soiled cloth bag should not have been on the clean linen cart. The dryer drum window was an infection control problem, since it was not a cleanable surface. Housekeeping staff should have changed their gloves and completed hand hygiene between each resident's room. Interview on 10/31/18 at 1:23 p.m. with the DON regarding the above observations revealed she: Would have expected the housekeeper to have changed gloves and completed hand hygiene between residents' rooms. Considered the duct tape on the dryer window an infection control issue due to it being a non-cleanable surface. Review of the provider's (MONTH) (YEAR) Bed Making policy revealed: 4. Dirty rags used to clean bed will be placed in a separated receptacle away from clean linen. Review of the provider's (MONTH) (YEAR) Equipment policy revealed: All equipment is to be in good working order and repair. -1. If equipment is not working properly or needs repair, maintenance is to be notified as soon as possible. -2. Fill out maintenance repair slip. -3. Make other staff members aware of improper working equipment-place a note, write in report book, etc. -4. Maintenance will notify staff when repairs are completed and equipment is in good working order. Review of the provider's 4/18/18 Hand Washing policy revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. -2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel. -6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: --a. When hands are visibly soiled. -7. Use an alcohol-based hand rub, alternately, soap and water for the following situations: --m. After removing gloves.	2020-09-01
149	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	585	E	1	0	QFLH11	> Based on interview and policy review, the provider failed to have a facility based system in place to document grievances brought to their attention by staff, residents, or family members. Findings include: 1. Interview on 11/28/17 at 11:00 a.m. with an anonymous family member revealed she had been yelled at by a staff member a few weeks back. While she could not recall the name of the staff member who had yelled at her, she identified another staff member who had witnessed the event. Interview on 11/28/17 at 11:15 a.m. with an anonymous staff member revealed: Earlier in the month she had overhead certified nursing assistant (CNA) C getting loud with the above family member and resident. She had been walking down the hall towards the residents' rooms when the voices started to get loud. She had walked into the room and heard CNA C yelling at the family member. She had reported the incident to the charge nurse. She was unable to remember who the charge nurse was that night. Interview on 11/28/17 at 1:30 p.m. with the social services designee and the director of nursing (DON) regarding their grievance process revealed they: Had no way of tracking grievances. Were unable to provide what grievances had been received since 9/18/17, and how those grievances were resolved. Stated grievances were handled on an individual basis but could not provide what grievances they had looked into and resolved. Interview on 11/28/17 at 1:45 p.m. with the administrator revealed: They currently had a grievance form that staff should have been filling out but were not. They were changing the process but had no timeline for when that would be implemented. The DON had received a note under her door on 11/27/17 regarding CNA C and her behavior being inappropriate towards family and residents. -The note had not been signed. They were waiting to talk to CNA C on 11/29/17, as that was the next shift she was scheduled to work. They had not started an investigation into the matter. They had not documented that as a grievance. Review of the provider's current undated grievance procedure revealed: A grievance is a complaint in which a resident (or family member) feels he/she has not been treated fairly, or that a mistake has been made in the resident's care or in the administration of a rule, plan, or policy. The policy had not addressed the grievance form or documentation of the grievance.	2020-09-01
150	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	610	E	1	0	QFLH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to thoroughly investigate falls for two of two sampled residents (1 and 4). Findings include: 1. Review of resident 1's 10/6/17 South Dakota Department of Health (SD DOH) event reporting form revealed: The fall had occurred at 4:30 a.m. The resident's wife had received a call at home from the resident asking her to contact the nurses in the facility, as he needed help. Staff received the call from the wife, and they found him sitting on the floor. Resident first stated he was sitting on his wheeled walker and fell asleep and woke up to falling onto the floor. Then later stated that he was trying to move his wheelchair to the hallway and fell . His left eye was swollen. His wife had taken him to the hospital where he was admitted for weakness, [MEDICAL CONDITION], and fall with periorbital hematoma. They will encourage resident to utilize his wheelchair (if still appropriate) and walker and not to walk on his own. Will keep call light in reach and make sure his cell phone is on his person, so if not within call light reach able to make contact with staff or wife. The administrator's name had been on the final investigation conclusionary summary. There had been no documentation regarding the following investigation areas: -Interviews conducted with the wife or staff members who had been working. -Where the call light had been located. -The last time he had been checked on. -What level of assistance he required. -If the care plan had been followed. -What the environment looked like upon entering the room. -If he had been assisted to bed and who last worked with him. -If there had been any medication changes. 2. Review of resident 4's 11/19/17 South Dakota Department of Health (SD DOH) event reporting form revealed: The fall had occurred at 11:30 a.m. Resident prone on floor beside tipped recliner. He had complained of pain to his left eye brow where an abrasion had been noted. Extensive assist of 2 to stand and transfer to bed. Resident moved closer to the nursing station and is reminded to use call light for assistance of which his dementia keeps him from remembering this. The administrator's name had been on the final investigation conclusionary summary. There had been no documentation regarding the following investigation areas: -Interviews conducted with the staff members who had been working. -Where the call light had been located. -The last time he had been checked on. -If the care plan had been followed. -Why the recliner would have tipped over. -If there had been any medication changes. 3. Interview on 11/28/17 at 4:00 p.m. with the administrator and the director of nursing revealed there had been no further documentation regarding the above incidents and the investigations. Review of the provider's undated How to Conduct an Investigation policy revealed: The investigation should have included: -Who. -What. -When. -Where. -How. Documentation is needed to reflect that the standard of care was met. *Any event that is not consistent with the routine care of the resident is worthy of investigation.	2020-09-01
151	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	658	D	1	0	QFLH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, interview, and policy review, the provider failed to ensure professional standards of practice were followed for one of one sampled resident (1) for: Receipt, transcription, clarification, implementation, re-evaluation, and follow-up to physician's orders. Appropriate nurse documentation of medication when not readily available in the facility versus refused by the resident. Findings include: 1. Review of resident 1's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Disorder of the kidney. -Muscle weakness. -Unspecified dementia. -[DIAGNOSES REDACTED]. -Essential hypertension. He had fallen on 10/6/17 at 4:30 a.m. Review of resident 1's 10/6/17 nursing progress note revealed: At 4:30 a.m. Received call from resident's wife asking for him to be checked on. -Resident called wife from personal cell phone and told her he needed help. -Resident checked on and found sitting on the floor. -Resident first stated that he was sitting on his wheeled walker and fell asleep but woke up as he was falling on the floor. -Then later stated that he was trying to move his wheelchair to the hallway and fell . -Noticed left eye was swollen. -No other injuries noted. -Vitals, range of motion, and neuro (signs) checked. -Doctor and spouse notified of event. --There had been no documentation regarding the recommendation from the physician regarding the resident hitting his head. At 9:39 a.m. Residents wife here with resident this AM. States that she called (physician's name) regarding fall this AM and plans to take resident to the (hospital name) ER (emergency room ) and to see (physician's name). At 10:05 a.m. Resident to (hospital name) ER via private vehicle accompanied by wife. Meds (medication) sent with. At 11:47 a.m. (Physician's name) updated that resident was taken to (hospital name) ER to see (another physician's name) with wife this AM following fall. At 5:10 p.m. Call received from (nurse's name) from (hospital name) states that resident was admitted for weakness, [MEDICAL CONDITION], and fall with periorbital hematoma. Review of resident 1's 10/6/17 event report revealed: He had an injury to his left eyebrow. The injuries noted were bump, redness, and swelling. They had not faxed the physician but had documented they had been notified at 5:04 a.m. There had been no documentation regarding what communication or recommendations the physician made regarding the injury to his head. Interview on 11/28/17 at 10:30 a.m. with resident 1 and his spouse revealed: He had [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. She had received a call on 10/6/17 at 4:10 a.m. from her husband asking her to contact the nursing staff as he needed help. She had called the facility, and then drove to the facility about forty-five minutes later. When she arrived and saw the injury to his eye she had been worried about his vision. She had notified her husband's physician at the Veterans hospital of his fall. She was told he should go to the hospital. She drove him herself to the hospital. He had been admitted into the hospital and had been there for one week. They wanted him to use the condom catheter at night, so he could sleep. Initially the nurses had used a product they had in the building that was too small and very old. She had requested they use the condom catheters provided by the Veterans hospital instead of the others, as she did not want her husband to be in pain. He stated it helped him be more alert throughout the day if he got sleep at night. 2. Review of resident 1's nurses' progress notes revealed on 10/12/17 he had returned from the hospital with a condom catheter in place. Review of resident 1's 10/12/17 hospital discharge paperwork revealed there was no order for a condom catheter. Review of resident 1's nurses notes revealed: On 10/12/17 at 3:00 p.m. he had been readmitted with a condom catheter. On 10/13/17 the condom catheter had come off and tore. -Staff had spoken to the wife and resident about not replacing the condom catheter to encourage resident with toileting and continence. There had been no documentation regarding clarification with the physician regarding the use of the condom catheter. Interview on 11/28/17 at 3:10 p.m. with the Minimum Data Set coordinator revealed there was no documentation of a physician's order for the condom catheter or clarification that resident 1 should have one. 3. Review of resident 1's physician's orders revealed on 11/1/17 the physician had ordered a condom catheter to be put on every night and taken off in the morning for nocturnal incontinence. They were to trial the condom catheter for two weeks. Then they were to reassess the purpose that was to decrease skin breakdown related to nocturnal incontinence. Review of resident 1's treatment administration records from 11/1/17 through 11/28/17 revealed: On 11/1/17, 11/2/17, and 11/3/17 NA (not available). From 11/4/17 through 11/8/17 staff had initialed as putting on the catheter. On 11/9/17 an R (refused) had been marked. From 11/10/17 through 11/13/17 NA had been marked. From 11/14/17 through 11/16/17 it was eligible and circled. From 11/17/17 through 11/19/17 NA had been marked. 11/20/17 had been initialed. 11/21/17 brief was written. 11/22/17 a dash had been marked. From 11/23/17 through 11/26/17 NA had been marked. 11/27/17 had been left blank. Interview on 11/28/17 at 1:30 p.m. with licensed practical nurse A and registered nurse (RN) B revealed: They were unsure of where the first condom catheters had come from. They now had the condom catheters from the VA but had not been using them. The NA on the treatment administration record meant not available. RN B stated the wife had requested he not wear them. -She agreed it was because the condom catheters used initially were not the right size and were old. There had been no communication with the physician regarding discontinuing the condom catheter. Review of resident 1's medical record revealed there was no documentation the physician had been notified about discontinuing the condom catheter. 4. Review of resident 1's physician's orders revealed on 11/1/17 the physician had ordered myrbetriq extended release tablets 25 milligrams everyday for urinary incontinence/overactive bladder. Review of resident 1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Observation and interview on 11/28/17 at 3:30 p.m. with licensed practical nurse A revealed: The R with a circle around it on the MAR meant the resident had refused the medication. The medication myrbetriq had not been in the medication cart. She had stated it was going to be discontinued and had been put into the cupboard. The cupboard had been searched, and the medication had not been there. She then stated it had been returned to the pharmacy. They had been marking refused on the Medication Administration Record [REDACTED]. There had been no physician's order to discontinue the medication. Review of resident 1's medication disposition sheets revealed: On 11/9/17 they had sent back eight myrbetriq tablets due to being overstocked. On 11/24/17 they had sent back twenty-six myrbetriq tablets due to the medication being discontinued. Review of resident 1's medical record revealed there had been no physician's documentation of an order to discontinue the medication. 5. Interview on 11/28/17 at 4:00 p.m. with the administrator and the DON revealed staff should have: Documented the physician's recommendations in the resident's medical record after the fall. Contacted the physician for clarification of use regarding the condom catheter after returning from the hospital, and prior to discontinuing the condom catheter and myrbetriq medication. Not have been marking refused on the MARs. They should have received an order for [REDACTED].>They were not sure why the staff had sent the medication back to the pharmacy. Policies for following physician's orders, clarification of physician's orders, and documentation had been requested of the administrator and DON but one had not been provided by the end of the survey. [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis., (YEAR), p. 367, revealed: Telephone orders (TOs) occur when a health care provider gives therapeutic orders over the phone to a registered nurse. Verbal orders (VOs) occur when a health care provider gives therapeutic orders to a registered nurse while they are standing in proximity to one another. TOs and VOs usually occur at night or during emergencies, they should be used only when absolutely necessary and not for the sake of convenience. The nurse receiving a TO or VO enters the complete order into the computer using the computerized provider order entry software or writes it out on a physician's order sheet for entry in the computer as soon as possible. [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis., (YEAR), p. 628, revealed: Nurses and other health care providers use accurate documentation to communicate with one another. Many medication errors result from inaccurate documentation. Therefore always document medications accurately at the time of administration and verify any inaccurate documentation before giving medications.	2020-09-01
152	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	584	E	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the provider failed to maintain and repair three of four sampled residents' rooms (117, 121, and 125) for the following: Paint walls after plaster had been repaired in rooms [ROOM NUMBER]. Repair chipped and broken sheetrock in rooms [ROOM NUMBERS]. Repair wood that was splintering in room [ROOM NUMBER]. Clean the showers in room [ROOM NUMBER] and 125. Stop leaking shower hose that caused a thick, slime to the floor of the shower in room [ROOM NUMBER]. Findings include: 1a. Observation on 12/9/19 at 4:04 p.m. of resident room [ROOM NUMBER] revealed: There was a piece of wood attached to the wall at the head of his bed. The piece of wood was splintered in areas. b. Observation on 12/9/19 at 4:21 p.m. of resident room [ROOM NUMBER] revealed: On the wall beside the bed there were white, unpainted drywall patches the length of the bed. In the shower there was a wheelchair (w/c). -The resident said was not hers. The hose to the shower was hanging with the shower head not attached to it. -There was water dripping from the hose to the floor. -There was a dark brown color on the floor with a clear slimy substance on it from where the hose was leaking and going to the drain. -There was a dead moth laying in the slimy substance. c. Observation on 12/10/19 at 11:22 a.m. of resident room [ROOM NUMBER] revealed: There was paint scraped off the wall by the head of his bed with several different colors showing through. The corner of the wall outside the shower had broken drywall from the floor up approximately one foot with crumbling pieces on the floor. All the corners in the room had broken drywall and scraped paint revealing the bare metal corner pieces. The toilet room had holes in the wall and the entire area if a vent covered in rust. His shower room had the following in it: -Three w/cs. -Four, one gallon containers on the floor. -A w/c seat cushion on the floor. -Blankets and an ankle-foot orthosis were sitting on the w/cs. -Small pieces of broken drywall covered the parts of the floor that were visible; the drywall on the inside of the doorway was broken and chipped. d. Interview on 12/11/19 at 8:47 a.m. with housekeeper B revealed: There was generally one housekeeper scheduled during the day. The housekeeper was responsible to clean all the residents' rooms and all the common areas in the facility. She had worked at the facility for a couple of years. She did not clean the showers in the residents' rooms, because they were not being used. In room [ROOM NUMBER] the shower room had been cleaned a month ago, and there was nothing in the shower room at that time. If there were two housekeepers working they would: -Clean the residents' bathrooms including the toilet, sink, mop the floor, and clean the mirror. -Sweep and mop the floor in the residents' rooms. -Dust window seals, television, and dressers depending on the amount of items on them. When one housekeeper was working that person would: -Do a total cleaning only if there was visible soiling in the rooms. -If there were no particles on the floor of the residents' rooms there would be no cleaning of it. When one housekeeper was working it was not possible to deep clean all the residents' rooms in a day. If there were maintenance issues they would either tell maintenance or complete a form at the nurses station. Interview on 12/11/19 at 1:58 p.m. with the director of nursing revealed: Housekeeping should do a deep cleaning of the rooms when a resident moved out of a room. Maintenance was in charge of housekeeping. She had been at the facility for about three years, and she worked on getting updates done to the tub room including adding a new whirlpool bathtub. When they got a new tub they had transitioned a lot of residents to baths and stopped using the showers. The residents could choose to use the shower, but it would have to be cleaned first. Interview on 12/11/19 at 3:24 p.m. with the environmental services (maintenance) supervisor revealed: Daily housekeeping should have used a thorough room cleaning audit checklist. -The housekeepers would put the dates to the right of the room numbers indicating what dates they had completed the tasks. --There was no way to determine which tasks were completed on which dates. Usually only have one housekeeper working a day. They should have used a different cleaning checklist when a new resident was coming into a room. He did not keep any of the maintenance forms that had been completed, so he was unable to provide any copies of those forms when requested. A preventative maintenance policy was requested from him. -At 3:40 p.m. he informed the surveyor there was no policy for maintenance.	2020-09-01
153	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	604	D	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to complete a physical restraint assessment for one of two sampled residents (28) that had restraint devices being used. Findings include: 1. Review of resident 28's medical record revealed she: Had been admitted on [DATE] after being discharged from the hospital. Had the following Diagnoses: [REDACTED]. Had a Brief Interview for Mental Status assessment score of three indicating a severe cognitive impairment. Observation and interview on 12/9/19 at 4:21 p.m. with resident 28 revealed: She was able to recall her name, the name of the facility she was in, approximately how long she had been in the facility, and the situation that had brought her to the facility. When asked about falls she said she had falls before she came to the facility but none since she had came here. She was laying in her bed with something clipped to her shirt, and a cord that led to under her body. She said it was to keep her from falling, because if she got up it would make a noise so she could get help. She said it was on her all the time and not just when she was in her bed. Her bed was in the lowest position. There was a geriatric (geri) chair in the corner of the room with a tray leaning against it. -She said those items were not hers. Observations revealed a personal alarm device was on resident 28 at the following dates and times: 12/10/19 at 9:31 a.m. she was in her bed. 12/10/19 at 1:17 a.m. she was in her bed. 12/10/19 at 2:27 p.m. she was in her bed. Review of the matrix care report with a last reviewed/revised date of 11/22/19 obtained from the Minimum Data Set (MDS) coordinator for resident 28 revealed: She stated what was on line was not updated, and this was the most up to date care plan. In handwriting on the last page were the following approaches:-Geri-chair (with lap) tray. Laptray on while in Geri chair. To be removed every 2 (hours) for 10 (minutes). -TABS (personal alarm device) alarm while in bed or recliner. Beside the above approaches in handwriting was: changed to (as needed) on 12/9 (resident) has extreme fluctuations in ADLs (activities of daily living) and mental status. The restraint assessments for resident 28 from the MDS coordinator on 12/11/19 at 2:40 p.m. were requested. On 12/11/19 at 5:20 p.m. the MDS coordinator stated they had not completed one for resident 28. On 12/11/19 a review of the physician's orders [REDACTED]. Geri chair with lap tray for patient safety to be used as needed. Tabs alarm on while in bed or recliner. *Both of the above were ordered by her primary physician on 12/3/19. Review of the provider's reviewed (MONTH) 2019 Restraints-Physical policy revealed: an assessment process was to be used in every situation to enable residents to attain or maintain the highest level of functioning and the least restrictive environment.	2020-09-01
154	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	609	D	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the provider failed to ensure a fall with injury was reported to the South Dakota Department of Health (SD DOH) in a timely manner and a thorough investigation had been completed for one of three sampled residents (38). Findings include: 1. Review of resident 38's medical record revealed: She had been admitted on [DATE]. Her [DIAGNOSES REDACTED].>-Muscle weakness. -History of falling. -Repeated falls. -Major [MEDICAL CONDITION], single episode. She had a fall on 11/17/19, hit her head, and was sent to the emergency room . Review of resident 38's 11/22/19 Minimum Data Set (MDS) assessment revealed: Her Brief Interview for Mental Status assessment score was six indicating her cognition was severely impaired. She required extensive assistance from one staff member for bed mobility, transferring, dressing, toilet use, and personal hygiene. She had a fall with injury since her last assessment on 11/11/19. Interview on 12/11/19 at 11:26 a.m. with the director of nursing regarding resident 38 revealed: They had not sent in a final report to the SD DOH regarding the investigation into her fall on 11/17/19 until this morning. They were sending in another report and noticed they had not sent in a final report. They had sent in other reports in between 11/17/19 and 12/11/19. Review of resident 38's 12/11/19 SD DOH final report revealed: The fall had occurred on 11/17/19. The documentation stated she took herself to the bathroom, but that conflicted with her MDS assessment. They had not completed an investigation into the fall. All the documentation in the report was of nursing notes from the time of the fall and after. There was no documentation of what had occurred prior to the fall, when the resident had last been assisted, or if the care plan had been followed. Review of the provider's undated Abuse policy revealed: Investigation of abuse situations is critical. The investigation process includes a thorough assessment of the resident involved, interviews and observations with the resident, interviews with the staff members and interviews with the person involved in the alleged abuse situation. *The results of the investigations must be reported to the State Department of Health within 5 working days of the incident and if the alleged violation is verified appropriate action must be taken.	2020-09-01
155	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	657	D	0	1	DTNP11	Based on interview and record review, the provider failed to ensure 1 of 14 sampled residents (22) care plans was updated to reflect the resident's recurring pressure ulcers. Findings include: 1. Review of resident 22's medical record revealed he had recurring pressure ulcers. Pressure ulcers had not been addressed on his current care plan. Refer to F686, finding 1.	2020-09-01
156	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	658	E	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure: Parameters for blood glucose (sugar) levels were defined for one of one sampled resident (35) who had excessively high levels. physician's orders [REDACTED]. One of one sampled resident (22) who had weight fluctuations was re-weighed according to the provider's policy. Vital signs and neurological (neuro) assessments were completed after a fall with a head injury for one of two sampled residents (13). Findings include: 1a. Review of resident 35's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Dependence on [MEDICAL TREATMENT]. -Dependence on supplemental oxygen. -Type 2 diabetes with mild nonproliferation diabetic retinopathy without [MEDICATION NAME], unspecified eye. -[MEDICAL CONDITION], unspecified. -Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. His Brief Interview for Mental Status (BIMS) assessment score was fifteen indicating his cognition was intact. Interview on 12/10/19 at 10:29 a.m. with resident 35 revealed he had problems with his blood sugar. He said at least once per week his blood sugar crashed. When questioned further he was not able to explain what that meant. Review of resident 35's blood glucose levels from 10/1/19 through 12/10/19 revealed: His blood glucose levels were over 300 milligrams per deciliter (mg/dL) for the following: -October: 28 out of 122 times. -November: 36 out of 119 times. -December to date: 9 out of 39 times. --His blood glucose levels were over 450 mg/dL for 16 out of those 73 times there were over 300 mg/dL. On 10/10/19 he had blood glucose levels under 50 mg/dL two times that day. Review of resident 35's physician's orders [REDACTED]. Review of resident 35's 11/25/19 care plan revealed he had one intervention that stated: (Resident name) will often have very high blood sugars. Call PCP (primary care physician) or on call MD (medical doctor) and notify. There were no parameters set for when to make that call. Interview on 12/11/19 at 9:50 a.m. and again at 4:00 p.m. with the director of nursing (DON) regarding resident 35's blood glucose levels revealed: She was not aware there were no parameters set for him. She stated he was non-compliant with following his diet. They did not have a policy on blood glucose levels. They had standing orders, but the only parameters set were to notify the physician when blood glucose levels were less then 50 mg/dL. -There was nothing set for when blood sugars were high. Interview on 12/11/19 at 2:05 p.m. with the medical director regarding resident 35's elevated blood glucose readings revealed: He stated there should have been some sort of parameters of when to notify the physician. He was not the resident's primary care physician, so he did not feel he could speak regarding him. b. Review of resident 35's current physician's orders [REDACTED]. Interview on 12/10/19 at 10:36 a.m. with resident 35 revealed he only wore oxygen at bedtime and during [MEDICAL TREATMENT]. He used to wear it all the time. Observation on 12/9/19 at 3:43 p.m. and at 6:01 p.m., 12/10/19 at 10:29 a.m., and 12/11/19 at 9:50 a.m. of resident 35 revealed he was not wearing oxygen during any of those times. Interview on 12/11/19 at 11:13 a.m. with registered nurse (RN) A regarding resident 35's oxygen orders revealed: He used to be on continuous oxygen when he was first admitted to the facility. -He was very dependent on it and would not leave the building without it. At some point he stopped wearing it as much but she did not know why. She thought the order was for as needed and not continuous. 2. Review of resident 22's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Heart failure. -[MEDICAL CONDITION]. -Chronic lymphocytic [MEDICAL CONDITION] of B-cell type in remission. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. Review of resident 22's 11/3/19 care plan revealed: He was to be weighed weekly due to a history of [MEDICAL CONDITION] and heart failure. His weights were to be monitored, and any gains were to be reported to the MD and dietary services. Review of resident 22's weights from 8/1/19 to 12/10/19 revealed: From 8/23/19 to 9/6/19: a 10 pound (lb) loss. -Weight was missing for the week of 8/30/19. From 9/13/19 to 9/20/19: a 7 lb gain. From 11/29/19 to 12/6/19: a 8 lb gain. There were no re-weights completed on those dates. Interview on 12/11/19 at 4:20 p.m. with the DON regarding resident 22 revealed: She believed the dietary manager would inform the certified nursing assistants if they needed to re-weigh a resident. She agreed a significant weight change should have a re-weight done. Interview on 12/11/19 at 5:20 p.m. with the dietary manager revealed: She only monitored the residents who triggered a 5% weight change in thirty days or a 10% weight change in six months. Resident 22 had not been brought to her attention for her to monitor. Review of the provider's undated Weight Monitoring System policy revealed: The interdisciplinary team will monitor each resident consistently and closely. Weights are taken (by nursing staff) at least monthly, weekly as ordered by the physician. If a patterned or significant weight loss or gain is noted, the resident is to be re-weighed using a consistent scale. Scales should be checked routinely for accuracy. Nursing staff is responsible for reviewing weekly weights, notifying appropriate disciplines of significant changes, and completing documentation. Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, re-weigh resident to verify weight and notify dietician. 3. Review of resident 13's medical record revealed: She had been admitted on [DATE]. Her [DIAGNOSES REDACTED]. Her BIMS assessment score was seven indicating severe cognitive impairment. Review of resident 13's nursing progress notes revealed: On 11/10/19 at 1:45 p.m., she was found calling for help and sitting on the floor in her room. -Her bed alarm had been beeping. -Blood had been noticed on her right hand. -She complained of left side pain just near her left breast. -She had a 3.0 centimeter goose egg over her left eyebrow. --She was unsure how it got there. -Her vital signs (vitals) were stable. -No complaints of headache, dizziness, or blurred vision. -Pupils equal, reactive to light, and accommodating. -Hand grasps strong and equal. On 11/10/19 at 7:14 p.m., the hematoma over her left eye was more pronounced. -Bruising noted in left corner of her eye. -Vital signs continued stable. -No neuro assessments had been documented. On 11/11/19 at 3:40 p.m., the bruising around her left eye and nose had spread to her right eye as well. Review of resident 13's vital signs report revealed: On 11/10/19: -At 1:45 p.m., oxygen saturation, blood pressure (BP), respirations (R), pulse (P), and temperature (T) had been documented. -At 2:15 p.m., BP and P had been documented. No other vitals or neuros had been documented. -At 2:30 p.m., BP and P had been documented. No other vitals or neuros had been documented. -At 2:45 p.m., BP and P had been documented. No other vitals or neuros had been documented. -At 3:15 p.m., BP and P had been documented. No other vitals or neuros had been documented. -At 3:45 p.m., oxygen saturation, BP, R, P, and T had been documented. No neuros had been documented. -At 4:15 p.m., BP and P had been documented. No other vitals or neuros had been documented. -At 4:45 p.m., oxygen saturation, BP, and P had been documented. No other vitals or neuros had been documented. -At 5:45 p.m., BP and P had been documented. No other vitals or neuros had been documented. -At 6:45 p.m., BP and P had been documented. No other vitals or neuros had been documented. -At 7:45 p.m., at 8:45 p.m., and at 9:53 p.m., oxygen saturation, BP, R, P, and T had been documented. No neuros had been documented. On 11/11/19: -At 9:01 a.m. and at 7:00 p.m., oxygen saturation, BP, R, P, and T had been documented. No neuros had been documented. On 11/12/19: -At 10:00 a.m. and at 7:30 p.m., oxygen saturation, BP, R, P, and T had been documented. No neuros had been documented. On 11/13/19: -At 8:44 a.m., oxygen saturation, BP, R, P, and T had been documented. No neuros had been documented. Interview on 12/10/19 at 3:00 p.m. with RN C revealed when a resident had a fall with a head injury we do vitals. She documented neuro checks, vital signs, pupils, and hand grasps. Interview on 12/11/19 at 3:08 p.m. with the DON revealed when a resident had an unwitnessed fall with a head injury her expectation would be that nurses would follow their policy. Review of the provider's undated Falls policy revealed: *If a resident should fall on your shift follow these steps: -Assess the resident. -Assist the resident off the floor after assessments. -Take vitals: Witnessed fall requires vitals 24 hours. Unwitnessed fall requires vitals for 72 hours. If resident hits head with fall vitals and neuro checks are as follows: Every 15 min (minutes) x (times) 4; every 30 min x 4; every hour x 4; then every shift to finish out the 72 hours.	2020-09-01
157	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	686	G	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure pressure ulcers were consistently monitored and documented, effective interventions were in place and updated, and the physician was notified of new opened areas for one of one sampled resident (22) who had recurring pressure ulcers. Findings include: 1. Review of resident 22's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Muscle weakness. -Constipation. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Heart failure. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -Chronic lymphocytic [MEDICAL CONDITION] of B-Cell type in remission. -[MEDICAL CONDITION]. -Hypertension. -[MEDICAL CONDITION]. Review of resident 22's 7/24/19 Minimum Data Set (MDS) assessment revealed: His Brief Interview for Mental Status (BIMS) assessment score was eleven indicating his cognition was moderately impaired. He required extensive assistance from one staff member for bed mobility, transferring, dressing, toilet use, and personal hygiene. He was not at risk for developing pressure ulcers. However he currently had one, stage two, facility acquired pressure ulcer. The skin and ulcer treatment interventions were: -Pressure reducing device in his bed and chair. -Nutrition and hydration intervention to manage skin problems. -Pressure ulcer care. -Application of ointments/medications other than to feet. Review of resident 22's 10/20/19 MDS assessment revealed: His BIMS assessment score was twelve indicating his cognition was moderately impaired. He required extensive assistance from one staff member for toileting and personal care. He was at risk for developing pressure ulcers. He did not currently have a pressure ulcer. He had moisture associated skin damage. The skin and ulcer treatment interventions were: -Pressure reducing device in his bed and chair. -Nutrition and hydration intervention to manage skin problems. -Application of ointments/medications other than to feet. Observation and interview on 12/9/19 at 5:33 p.m. with resident 22 revealed: He was sitting in his recliner. He often got sores on his bottom and pointed to the left side of his buttocks. He had a cushion in his recliner to help with the sores. He slept in his recliner and not in his bed. He used a walker. Interview on 12/10/19 at 9:04 a.m. with registered nurse (RN) A regarding resident 22 revealed he took himself to the bathroom. Observation on 12/10/19 at 9:13 a.m. in resident 22's room revealed the gel cushion in his recliner was approximately one inch thick. The gel was an orange color. Looking down at the cushion the four corners appeared to be darker in color. Upon lifting up the cushion from the corner it stuck to this surveyor's hand. The gel was leaking out of the cushion. The top of the cushion had wrinkles across the whole thing. Observation on 12/10/19 at 10:18 a.m., 1:49 p.m., 3:07 p.m., 3:54 p.m., and 5:20 p.m. and again on 12/11/19 at 8:31 a.m. of resident 22 revealed he was sitting in his recliner in his room with the above mentioned gel cushion in the chair. Interview on 12/11/19 at 11:10 a.m. with RN A revealed the certified nursing assistant had just gone on break at 11:00 a.m. but would be back to take resident 22 to the bathroom at 11:30 a.m. That had contradicted what she had said above about him taking himself to the bathroom. Surveyor: Observation on 12/11/19 at 11:20 a.m. of resident 22 with RN A revealed: A dark, red oval area to his buttocks that went from his gluteal crease to both buttocks. -It covered approximately half the width of his buttock and the entire length of the buttock. The left gluteal buttock had a darker red area towards the crease of his buttock approximately a quarter in size. No drainage noted to any of the areas. He denied pain when asked if it hurt. Surveyor: Interview on 12/11/19 at 1:55 p.m. with RN A regarding resident 22 revealed: He had struggled with pressure ulcers for a long time. He had a wound that was continually opening and closing. His most recent wound had healed on 12/8/19. She was considered the wound nurse but had not had any special training in wound care. Wound measurements were supposed to be done weekly. All wound documentation was under nursing progress notes or an Event assessment if it was a big wound. -She could not explain what a big wound was. They had a wound specialist outside of the facility they could call if they needed to, but they had not contacted that person regarding the resident. She referred to that type of skin condition as recliner butt. Review of resident 22's nursing progress notes from 6/1/19 to 12/11/19 revealed: From 6/30/19 through 7/30/19: -6/30/19: a small open area on left buttock. Resident states that it is painful to touch. Area 0.2 cm (centimeter) X (by) 0.2 cm bag balm applied to buttocks as ordered. -7/4/19: No open areas noted to buttocks. -7/5/19: No open areas noted to buttocks. -7/18/19: Area on left buttock is getting larger and it is bleeding. Resident states that it is painful. Area 0.5 cm X 0.5 cm. Bag balm applied to buttocks as ordered. -7/18/19: physician notified and order to apply meplix dressing to left buttock, check daily, change q3d (every 3 days) and PRN (as needed) until healed. -7/24/19: Left buttock is showing improvement. Measures 0.3 (cm) X 0.2 cm. Area clean, no bleeding, scabbed over. Surrounding tissue intact. -7/26/19: Stage 2 pressure ulcer to left inner buttock is healing. Treatment in place. -7/30/19: Buttocks has no further open area. --There was no documentation of his physician being notified of the opened area until 7/18/19. --There was no documentation of staging or identifying it as a pressure ulcer until 7/26/19. 9/2/19: Area to resident's upper Left buttock reopened, area approximately 0.5 cm in diameter, wound bed pink with calloused skin surrounding. 9/4/19: Was seen by wound nurse yesterday, new orders processed for Collagen/anasecpt mixture to Lt. upper buttock stage 2 pressure ulcer daily until healed-cover with meplex. 9/10/19: Treatment done to Lt, buttock, pin point open area remains. 9/16/19: Treatment done to left lower buttock. Area has thin layer of skin but to look like a scrape. Measures 1.2 cm X 0.8 cm round with no coloring surrounding area is healthy skin. 9/18/18: Area has no open areas and is healed, but will continue dressing until skin is less fragile. 10/11/19: Left buttock does have a scab that is 0.2 cm round area cleansed and bordered foam dressing applied. 10/14/19: Changed dressing on left buttock and noted 0.2 mm (millimeter) scab that is round, no discharge or s/s (signs and symptoms) of infection noted at this time. 11/24/19: Resident has 4 small open areas to buttock; right side: 0.2 (cm) X 0.5 cm, 0.4 (cm) X 0.2 cm, 0.3 (cm) X 0.2 cm; Left side: 0.1 (cm) X 0.4 cm. Staff to apply bag balm with each brief change for barrier protection. N.O (nursing order) to monitor open areas daily until healed, notify MD (medical doctor) if worsening or s/s of infection noted. Staff and resident also encouraged to reposition when sitting in recliner throughout the day and night. 12/8/19: Open areas to buttocks healed, new pink skin, will continue with bag balm with brief changes. The documentation was inconsistent and lacking regarding staging, measurements for depth, descriptions, and physician notification. Review of resident 22's following skin assessments with the Braden Scale scoring revealed: 7/24/19: -His risk factors were not marked such as cardiovascular disease and terminal illness/cancer. -He was scored at twenty-two indicating he was not at risk for developing pressure ulcers. --He currently had a stage 2 pressure ulcer to his bottom. 10/20/19: -His risk factors were not marked such as cardiovascular disease and terminal illness/cancer. -He was scored at twenty-two indicating he was not at risk for developing pressure ulcers. -He currently did not have a pressure ulcer. Review of resident 22's following event reports revealed: 11/24/19: he currently had an opened area caused from moisture/shearing. -As of 12/11/19 the 11/24/19 event report had not been completed. There were no other event reports for any of the above mentioned pressure ulcers. Review of resident 22's 11/3/19 care plan revealed: There was no problem area for pressure ulcers. There was a problem area for (Name) experiences frequent bowel and bladder incontinence. -Interventions were: --[MEDICATION NAME] cream to groin and penis as ordered; approach date 5/7/19. --Bag balm to buttocks with each brief change; approach date 2/7/18. --(Name) received a multivitamin as ordered; approach date 11/29/17. --High protein snack BID (twice per day) to prevent skin breakdown; approach date 11/29/17. --Pressure reducing mattress to bed and gel cushion in recliner; approach date 11/29/17. --Receives [MEDICATION NAME] as ordered; approach date 8/14/17. --(Name) wears a brief at all times. Requires extensive assist with hygiene after incontinent episode; approach date 5/30/17. --Report any signs of skin breakdown (sore, tender, red, or broken areas); approach 5/30/17. --Report signs of UTI (urinary tract infection) (acute confusing, urgency, frequency, bladder spasm, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine); approach date 5/30/17. There were seven interventions that had no change since (YEAR). Interview on 12/11/19 at 4:20 p.m. with the director of nursing regarding resident 22 revealed: She knew he slept in his recliner. She was not aware of the state of the gel cushion. -He was sleeping when attempting to show her the cushion. -She stated she would come back later to look at it. She was not aware his care plan had not included his pressure ulcer injuries. -She tried to find documentation in his care plan, but stated I do not see it in there. Documentation regarding pressure ulcers was supposed to be done in the nursing progress notes or on a event report. Nurses were to notify the physician of new and worsened pressure ulcers. Review of the provider's policy regarding Pressure ulcers/impaired Skin revealed: Nurse on duty when pressure ulcer/impaired skin integrity is discovered, will perform an assessment. An assessment includes measurement of area affected including Length, width and diameter. Character of wound bed, any drainage, or odor or condition of surrounding skin, and complaints of pain. The nurse will then notify medical doctor with assessment and follow recommendations/orders given. Documentation of the pressure ulcer/impaired skin integrity to be done in a Matrix event or progress note. Regular documentation of impaired skin integrity to be done until area healed. Pressure ulcers will be followed and assessed weekly by designee. Notify dietary department of wound. Observations will then be completed until area is healed. MDS coordinator to be notified of pressure ulcer/impaired skin integrity. *MDS will be updated accordingly.	2020-09-01
158	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	689	G	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to assess and monitor one of one sampled resident (37) who was at risk for coffee burns. Findings include: 1. Observation on 12/9/19 at 5:24 p.m. revealed resident 37 was seated in his wheelchair in the dining room with an enclosed coffee mug. It was in a holder on the right side of his wheelchair (w/c). Interview on 12/10/19 at 8:46 a.m. with registered nurse C regarding resident 37 revealed he had a burn on his upper, right outside leg area due to spilling hot coffee. He had informed her he had switched his coffee from his mug to a paper cup. The coffee had spilled out of the paper cup. Review of resident 37's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of resident 37's 3/5/19 annual Minimum Data Set (MDS) assessment and his 11/22/19 quarterly MDS assessment revealed: His Brief Interview of Mental Status (BIMS) assessment score was fifteen indicated he was cognitively intact. He had no behaviors. He had upper extremity impairment on one side. He was independent with eating after set-up assistance. His quarterly MDS progress note revealed: -He was alert with intermittent confusion. -Both his legs had scattered scabbed over areas and very dry skin. -He used a w/c to propel himself around his room and the facility. -He was independent with eating after set-up help. Review of resident 37's culinary service progress notes revealed: On 5/29/19: he had a cup of coffee on his w/c that he drank from all day. On 8/22/19: he drinks a lot of coffee throughout the day. Review of resident 37's 11/19/19 mini-nutritional assessment revealed: He drank greater than five cups a day of fluid (water, juice, coffee, tea, and milk). He fed himself with some difficulty. He drinks coffee continually no way to measure how much fluid he is getting as multiple people fill his cup during the day. Review of resident 37's nursing progress notes revealed: On 11/30/19 at 9:09 p.m.: he was noted to have peeling skin on the top and side of his right thigh, when asked what happened he stated that he spilled hot coffee on it earlier in the day, and that he put cold water on it. Area appears to have blistered and then popped, area is red in color and resident states that it does hurt especially when he bumps it. On 12/1/19 at 3:27 p.m.: he was seen by his physician and same order for burn to his right thigh continued. On 12/2/19 at 10:38 a.m.: Areas at right upper leg redressed at this time. Areas measured. Top of outer right leg burn area measures 12 cm (centimeters) x (by) 8 cm and 1 mm (millimeter) deep. Areas all beefy red and no s/s (signs or symptoms) of infection noted at this time. Small area noted above outer area that measures 1.8 cm x 2 cm and 1 mm depth. Area at inner right upper leg measures 18 cm x 6 cm and 1 mm depth. Smaller area above large area measures 2 cm x 2 cm and 1 mm depth. Areas cleansed and [MEDICATION NAME] applied with new dressings over area. Kling around dressings. Resident denied pain at throughout dressing change. On 12/3/19 at 3:11 p.m.: Wounds cleansed with mild soap and applied [MEDICATION NAME] cream as ordered, covered with nonadherent dressing and wrapped with kerlix. No s/s of infection at this time. On 12/3/19 at 9:30 p.m.: Treatment done as ordered to burn on right thigh. No s/s of infection. Area is sore, while dressing is changed. There is a small area of blistering to lower part of thigh. 1st Degree Burned areas are red in color. There are also areas of 2nd degree burns. On 12/5/19 at 10:13 p.m.: Treatment done as ordered to burn on his right thigh. Cleansed wound with sterile water and soap, pat dry, applied silver [MEDICATION NAME] to burns, covered with nonadhesive dressing, and wrapped in kerilex. No s/s of infection. Resident given scheduled pain medication 30 minutes before doing treatment. Resident rates pain '9/10; constant pain'. Area is painful to touch while dressing is being changed. 1st [MEDICAL CONDITION] 2nd [MEDICAL CONDITION] present and red in color with serosanguineous drainage. Resident tolerated treatment well. On 12/6/19 at 11:14 a.m.: Treatment to right thigh burn done per doctor's orders. Areas show no s/s of infection and are showing improvement since day of first burn. There are no blistered areas, all open at this time. 2nd degree areas are bright red in color, boarders are approximated and clean. Resident complains of 'mild' pain while doing treatment. He states that if he bumps it or his pants are too tight the pain is 'horrible'. He states he does not need anything for the mild pain he is experiencing right now and that 'it goes away after you stop touching it'. On 12/7/19 at 6:20 a.m.: Treatment done to right thigh as ordered. Scheduled pain medication was given 30 minutes before treatment. Area showing improvement since last time this writer changed dressing. No signs of infection. 2nd [MEDICAL CONDITION] bright red in color. Borders are approximated and clean. Resident tolerated treatment well. Resident states '7/10' pain during dressing change and once complete it goes down quite a bit. Resident called me back to room to re-do the wrap due to it sliding down when standing/sitting. On 12/7/19 at 10:50 a.m.: Treatment done to right thigh as ordered. No filled blisters noted. All areas are open with skin pealing. Moderate amount of yellowish drainage on old dressings. Wound beds are beefy red in color. Small area towards the top right thigh has yellow slough noted. Resident states that pain is getting better but is still bothersome. On 12/7/19 at 9:30 p.m. recorded as late entry on 12/8/19 at 3:14 a.m.: Treatment done to right thigh area, as ordered. No s/s of infection. Resident tolerated well. Areas are healing. Clenased (sic) with [NAME]on, and [NAME]on/sterile water. Generous amount of [MEDICATION NAME] applied over all burned areas. Covered with three 15 x 15 cm Eclypse Super absorbent dressings, when wrapped with Kerlix. On 12/9/19 at 10:03 p.m.: Treatment done to right thigh as ordered. Cleansed with [NAME]on & [NAME]on soap with water, pat dry, applied Siladene, covered with non-adhesive bandages, and wrapped with Kerlix. Scheduled pain medication given 30 minutes before treatment was started. No signs of infection the the (sic) area. Burn areas are healing well. Resident rated pain' 7/10; but feels way better now' during treatment. Will continue to monitor area. On 12/10/19 at 7:02 a.m.: Areas at right upper leg redressed at this time related to having shower this AM. Area of burn covered until after shower. Areas measured. Top of outer right leg burn area measures 9 cm x 7 cm and 1 mm deep areas. Small area noted above outer area is healed and granulated in with new skin. Area at inner right upper leg measures 12 cm x 6 cm and 1 mm depth. Smaller area above large area is now granulated in with new skin and no s/s of infection noted. Areas not healed are beefy red in color with no s/s of infection noted. Areas cleansed and [MEDICATION NAME] applied with new dressings over area. Kling around dressings. Resident denied pain at throughout dressing change. No s/s of infection noted. On 12/10/19 at 9:30 p.m. recorded as late entry on 12/11/19 at 4:32 a.m.: Treatment done to right thigh area, as ordered. No s/s of infection. Resident tolerated well. Areas are healing, and not as sore when treatment done. Clenased (sic) with [NAME]on, and [NAME]on/sterile water. Generous amount of [MEDICATION NAME] applied over all burned areas. Covered with non-adherent dressing, then wrapped with Kerlix. Review of resident 37's 9/3/19 care plan revealed: A hand written notation 11/30 burn. Problem areas related to his: -History of [MEDICAL CONDITION]. -Memory problems related to his dementia and impulsive decision making following [MEDICAL CONDITIONS]. -Risk for falling related to impaired and impulsive decision making. -Self care deficit related to his [MEDICAL CONDITION]. No problem, goal, or approach had been noted regarding his coffee consumption and potential for coffee burns. Review of resident 37's 12/10/19 care plan approaches started on 11/30/19 revealed: He had [MEDICAL CONDITION] the top part of his left thigh/groin due to getting his own coffee. -Treatment was in place. He will often not wait for assistance in getting coffee. Makes attempts to get it on his own. Staff to reeducate on the importance and safety of staff assisting him. Remind and educate (Name) that if he is not in the dining room, coffee must be in a closed cup with proper fitting lid for his safety. Interview on 12/11/19 at 1:42 p.m. with the Minimum Data Set assessment coordinator regarding resident 37 revealed: He was known to be an avid coffee drinker. He should have been assessed as at risk for coffee burns. She had done the hand written note on his previous care plan regarding the 11/30/19 burn. His care conference had been on 12/6/19. -His care plan had been updated after that care conference. He had been given a covered coffee mug. -Areas of the facility with access to coffee now had locks on the doors. Interview on 12/11/19 at 2:28 p.m. with the director of nursing regarding resident 37 revealed: She knew he liked his coffee and drank it morning and night. He demanded his coffee be extremely hot. -If his coffee cooled down he would throw it out and demand to get hot coffee. They had given him several different coffee mugs. -The lid on his current coffee mug basically locks. She had numerous conversations with him regarding the temperature of his coffee. Since his burn he had not been as demanding for extremely hot coffee. They knew he was at risk for spilling his coffee. He should have been assessed [MEDICAL CONDITION] to extremely hot coffee. His care plan should have included approaches related to his risk of coffee burns. Review of the provider's 12/5/19 Hot Beverage policy revealed: Hot beverages for drinking would be filled in a carafe before meal service, so the liquid could cool down. If a resident expressed a desire for very hot coffee or water and was safe to handle it they might have the hot liquid out of the machine. *Any coffee taken out of the dining room must have been in a covered cup with a tight fitting lid.	2020-09-01
159	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	812	E	0	1	DTNP11	Based on observation and interview, the provider failed to ensure two of two Manitowac water/ice machines were maintained in a clean, operable condition. Findings include: 1. Observation on 12/9/19 at 5:51 p.m. of the Manitowac water/ice machine in the north dining room revealed a large amount of mineral (lime) build-up on the surface, catch grate, and catch tray of the machine, and on the stainless steel table. Observation on 12/9/19 at 5:53 p.m. of the Manitowac water/ice machine in the hallway by the kitchen revealed mineral (lime) and rust build-up on water catch tray grate of the machine. Interview on 12/11/19 at 3:15 p.m. with the maintenance supervisor confirmed the above observations. Further interview revealed cleaning of both water/ice machines was not on the preventative maintenance schedule. Interview on 12/11/19 at 3:30 p.m. with the dietary service manager revealed the water/ice machines were not on dietary's cleaning schedule.	2020-09-01
160	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	600	H	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to: Provide necessary care in services resulting in neglect and resident-to-resident altercations for two of two sampled closed resident record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit (MCU). Implement a resident-specific care plan that included evaluations and revisions of interventions to prevent abuse and neglect for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Provide supervision and monitoring of the delivery and implementation of care for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Ensure effective communication between nursing and direct care staff and health care providers regarding physical and verbal abuse for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Contact the primary physician at the time of an acute change in condition that required the plan of care to be revised to meet the residents' needs in a timely manner for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. Ensure staff responded professionally to medical and psychiatric emergencies for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. Ensure thorough orientation upon hiring for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Review of a South Dakota Department of Health (SD DOH) initial Required Healthcare Event Reporting form completed by the director of nursing (DON) regarding resident 1 that had been sent to the SD DOH on 2/23/18 revealed: The type of event being reported was Suspicion/allegation of abuse/neglect on 2/22/18 at 5:40 p.m. The allegation type was Physical harm/injury. Under the heading Suspicion/Allegation of Abuse/Neglect: Resident to resident /Patient to patient. Both Names and Cognition. (Resident 1) (Resident 2) Both residents have dementia and live in our memory care unit (MCU). * A brief explanation of the event indicated: (CNA/UAP E) was in the medication room when she heard a loud bang. She immediately went to investigate to find (resident 1) laying on the floor bleeding from her nose and mouth. (Resident 2) was standing beside (resident 1) mocking her when (CNA/UAP E) found them. Large bump to the back of (resident 1's) head when assessed by nurse. Resident was sent to ER. Social worker notified at the time of the fall but unaware of the circumstances. Management staff are made aware of the situation after reading notes this morning. The law enforcement had been notified on 2/22/18 at 6:00 p.m. due to Assault of resident. The Department of Social Services had not been notified. Review of the SD DOH final Required Healthcare Event Reporting form for resident 1 sent to the SD DOH on 2/23/18 revealed the conclusionary statement: The initial SD DOH facility event report statement was included. On 2/23/18 at 8:30 a.m.: Staff development nurse called (the medical director/Resident 2's primary physician) regarding incident and requested a return call ASAP. 8:45 a.m. DON, infection control nurse (LPN J), staff development nurse (LPN A) spoke with CNA/UAP [NAME] about the events that occurred the previous day. CNA/UAP [NAME] had reported: She had been in the medication room when the event occurred. CNA/UAP H had been in the common room with all nine residents present. CNA/UAP [NAME] heard a loud thud and came out to investigate the noise. She found: -Resident 1 on the floor in the hallway between the door of her room and the common area, bleeding from her nose. She was lying on her back and attempting to roll to her side to get up. -Resident 2 was standing over resident 1, Mocking her for crying and verbally berating her. -As CNA/UAP [NAME] was assisting her to sit up, she began bleeding from her mouth. -CNA/UAP [NAME] laid her on her back on the floor to redirect resident 2 away from resident 1, and contacted the nurse by phone. -Once CNA/UAP [NAME] had notified the nurse CNA/UAP H: --Exited the bathroom. --Attempted to redirect resident 2 away from the area as he continued to mock resident 1. -At that time LPN B entered the MCU. -She attempted to obtain resident 1's vital signs but was unsuccessful. -She contacted 911 for transport. -Family was notified, and PCP (primary care physician) was faxed about the incident. -Resident 1 was transported by ambulance to the emergency room at 6:17 p.m. -CNA/UAP [NAME] reported she had not been gone from the common room for more than two minutes when the event had occurred. The above report went on to document: On 2/23/18 at 10:30 a.m. the infection control nurse had attempted to contact the medical director/resident 2's physician's personal cell phone. At 11:30 a.m. the infection control nurse had contacted the medical director/resident 2's physician's office and spoke to the receptionist. Message left with the receptionist regarding the severity of the situation and the urgency of needing to speak with the physician. At 11:40 a.m. the infection control nurse had received a phone call from another doctor, and they discussed resident 2's background and behavioral history. -She received a verbal order to send resident 2 to the emergency room for an evaluation. At 11:45 a.m. the staff development nurse contacted resident 2's wife and notified her he was being transported to the emergency room . At 12:15 p.m. he was transported to the emergency room . Documentation at the end of the conclusionary summary stated: In conclusion abuse/neglect has not been substantiated at this time due to lack of proof of any wrong doing. -The police department was investigating the incident. Documentation below the conclusionary summary stated: -Was abuse/neglect allegation substantiated? was marked N/[NAME] There was no proof/witness to substantiate. Police are investigating at this time. -Action taken by the facility: Resident that possibly caused harm was removed from the facility and transferred (to a) facility that can meet his behavioral needs. Interview on 3/7/18 at 8:10 a.m. with CNA/UAP [NAME] regarding the above event on 2/22/18 revealed she confirmed the above conclusionary report and added: She had worked as a restorative aide until 3:30 p.m. that day. She had worked on the MCU from 3:30 p.m. until 6:30 p.m. with CNA/UAP H. Supper was finished between 5:15-5:30 p.m. CNA/UAP H had wheeled the MCU supper cart to the kitchen and returned to the MCU. CNA/UAP [NAME] then went to the medication room next to the common area to finish setting up the supper medication. Residents 1 and 2: -Had been placed at separate tables. -We always sat them at different tables. -Resident 1 had frequent repetitions of the word [NAME], [NAME], [NAME] that would cause resident 2 to become upset with her. -CNA/UAP H was in the bathroom when the event occurred. -She came out of the bathroom at the time LPN B entered the MCU. -LPN B was unable to get vital signs, but resident 1 was resisting. -After resident 1 had been transported to the ER resident 2 had stated, They called the cops at me. -Resident 2 had remained on the MCU. -CNA/UAP [NAME] had left the MCU at approximately 6:35 p.m. -CNA/UAP H remained on the MCU to care for the residents alone. -Resident 2 was still on the MCU when CNA/UAP [NAME] returned to work the following day. Resident 2's behaviors: -Were OK when he had been admitted to the MCU. -Became worse and worse over the last couple months. -Had received medication changes due to his worsened behaviors, but the behaviors had not changed. -Because of his worsened behavior CNA/UAP [NAME] had not been comfortable working on the MCU alone. -When asked if she had discussed her discomfort with his behavior, she stated Not really. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding the above event on 2/22/18 revealed she: Worked as day shift charge nurse on the Warren and MCU units. Went to the MCU at 1:00 p.m. to administer a medication. Returned again at around 5:40 p.m. after she received the phone call from CNA/UAP E. Confirmed the events on the SD DOH event report conclusionary summary statement. Had not known resident 2 had behavior issues until that day. Entered the unit to find resident 2 standing over resident 1 mocking her. Instructed CNA/UAP H to get CNA I. Lifted resident 1 by the pants from the floor to her wheelchair with CNA/UAP I's assistance and wheeled her to her room. Used a flashlight to find the cause of the bleeding in her mouth. Was unable to obtain vital signs. Did not attempt to obtain neurological checks. Left the CNAs on the MCU while she went back to the Warren unit to call the ambulance. Did not know how to call out for 911, so called the other nurse in the building for instructions. Informed the emergency medical system (EMS) person of resident 1 possibly being pushed or hit and answered yes when the EMS person had asked if the other person remained in the building. Had not known how to fill out paperwork for a transport, so the oncoming LPN C assisted her. Stated: -There was no written instruction on how to handle emergency situations. -She had not received orientation regarding emergency situations. -LPN C was her only contact to assist her to handle the situation. Stated the licensed social worker (LSW) was still in the building, and he told LPN C to tell LPN B to: -Fax the physician about the fall. -Get a fax order from resident 2's physician to get resident 1 moved. LPN B stated the LSW: -Wanted to wait for the fax order follow-up for resident 2. -Did not enter the MCU during the event or after resident 1 had been transported to the ER. LPN B: -Called resident 1's power of attorney to notify him of the injury and transport to the ER. -Faxed resident 1's primary physician regarding the event. -Did not notify the director of nursing or the administrator of the event. -Did not notify resident 2's family about the event. -Did not immediately phone resident 1 or 2's physicians about their significant change in status. When asked if LPN B had observed any other aggressive incidents by resident 2 she stated: She had been called back to the MCU on the evening of 2/21/18 by CNA D to check resident 1's chest. CNA D had told her resident 1 had been Punched in the chest. -LPN B stated she: -Did not think it had occurred at that time. -Had not asked who punched resident 1 or when it had occurred. -Thought it happened earlier and the aide wanted her to follow up on it. -Had looked at her chest and placed a note in her chart. -Had not completed an event report. -Had not reported it to other nursing staff. Interview on 3/7/18 at 10:15 a.m. with CNA/UAP H regarding the 2/22/18 event revealed: She came to work at 10:30 a.m. CNA/UAP [NAME] came to work in the MCU at 3:30 p.m. After the supper meal was done CNA/UAP [NAME] went to the medication room to get medications ready. The residents were fine, so she went into the bathroom. When she came out of the bathroom she saw resident 1 on the floor. She confirmed the events according the SD DOH conclusionary report and added that after resident 1 was transported to the ER: -Resident 2 was agitated and mentioned he was going to jail. -He had threatened to harm other residents and her. -She confirmed she was scared by his threats. -She immediately told the nurse (LPN C) about his threats to harm others. -Sometimes he would become verbally aggressive, but she had never seen him harm anyone before. -Later that evening he went to his room and stayed there. -CNA/UAP H left the MCU at around 9:00 p.m. Interview on 3/7/18 at 10:12 a.m. with CNA F regarding the event on 2/22/18 revealed she: Came to work on MCU at 6:00 p.m. and worked there until 6:30 a.m. the following morning. Thought resident 2 was already in bed when she reported to the MCU. Stated he slept all night getting up one time to the bathroom. Was not afraid of him. Checked all residents every two hours, and thought the nurse had told her to check on resident 2 every hour. Did not recall having worked with CNA/UAP H that evening. Did not remember resident 2 raising a fist at her. Had never seen resident 2 hit or push other residents. Did observe resident 2 become verbally aggressive with residents. Used the pocket care plan to guide her care of the residents. Interview on 3/7/18 at 11:11 a.m. with the LSW regarding the 2/22/18 resident-to-resident altercation revealed he: Had clocked out and was walking through the facility at 6:00 p.m. when LPN C informed him I think (resident 2) may have pushed someone down, and they need to go to the hospital. Instructed LPN C to let the administrator or the director of nursing know. Denied he had recommended to LPN C to fax resident 2's primary care physician (PCP) regarding a behavioral health referral. Stated It was more hearsay than reportable so I left. Stated, I thought it was being handled. Had heard of other occasions that resident 2 had pushed others, but he did not get involved. Was not involved with reviewing event reports. Did not assess resident 2's behavioral problems and said, I did not actively think about how (resident 2) would act after the situation. Further interview at the above time with the LSW revealed: The interdisciplinary team gathered daily at 9:00 a.m. for a stand-up meeting to review any resident's concerns. -They reviewed falls. -Resident behaviors were not reviewed routinely. The CNAs documented resident's behaviors. He: -Imported resident behavior reports to review for the seven-day look back at the time of each residents' Minimum Data Set assessment. -Did not review the days that were not in their seven-day look back. -Was more involved with missing money or elopements. -Was not involved with resident-to-resident behavior. -Was not aware the CNAs attempted to keep residents 1 and 2 separated in order to prevent resident 2 from becoming aggressive toward resident 1. Interview on 3/7/18 at 2:20 p.m. with infection control/staff development LPN J regarding altercations between residents 1 and 2 revealed: She had been aware of resident 2's episodes of verbal aggression but had not been aware of physical aggression. She was aware of the 12/14/17 event but did not remember the altercation had been intentional.She vaguely remembered the 1/24/18 event when resident 1 had been pushed. She had recalled reviewing the 1/24/18 event at a stand-up meeting, but had not put it together to report the event to the SD DOH. The LSW would not have been involved with that type of event. The LSW would talk to a resident if their behavior was inappropriate such as touching but not for physically aggressive behaviors. Interview on 3/7/18 at 4:35 p.m. with LPN C regarding the 2/22/18 resident-to-resident altercation revealed she: Worked the 6:00 p.m. to 6:30 a.m. shift. Was scheduled as the charge nurse on Warren and memory care units that date. Was aware of resident 2's aggressive behaviors. Was informed by LPN B of the fall event in the memory care unit. Reported to LSW on 2/22/18 at approximately 6:30 p.m. that she heard two different stories: resident 2 hit resident 1 or they suspected he hit her. Was instructed by the LSW to fax resident 2's doctor to get an order to send him to behavioral health. Was not instructed by the LSW to call the administrator and/or the director of nursing. Stated the LSW left the facility and did not assess the situation to ensure the safety of other residents. Acknowledged on 2/22/18 at approximately 8:00 p.m.: -CNA/UAP H had reported to her resident 2 raised his fist at her and tried to hit her. -She had instructed CNA/UAP H to ignore resident 2 and leave him alone. -She told her she would go back to memory care to check on him. There was no communication to the PCP regarding resident 2's behaviors. She had not documented in the interdisciplinary progress notes (IPN) regarding having monitored resident 2's behaviors. When asked if there was protocol for notifying the DON or administrator about incidents LPN C stated: I think we are supposed to notify the DON or administration if a resident was hospitalized . She probably should have followed up with LPN B regarding what resident reporting she had done before she left. She had not known what LPN B completed for notification before she left the building. I didn't really think of calling. Interventions for resident 2's aggressive behavior was to redirect/steer other residents away from him and hope he did not follow. Review of resident 1's medical record revealed:She had been admitted on [DATE]. She resided on the memory care unit. A 12/12/17 physician's progress note indicated: -[DIAGNOSES REDACTED]. -No longer even to do social chatter. -[MEDICATION NAME] had been helpful for anxiety and agitation. -She was quickly declining cognitively. -She walked with a shuffled gait, head held down. A 12/27/17 order to change [MEDICATION NAME] from three times daily to as-needed. A 1/31/18 fax to the primary physician to discontinue the as-needed [MEDICATION NAME], because she had not used the prescription in the last fourteen days. That order was approved. A 2/13/18 physician's progress note revealed:-She was seen at the Veteran's Administration (VA) Hospital. -The VA physician had changed her [MEDICATION NAME] from a scheduled dose to as-needed. -The same physician had also added [MEDICATION NAME] (to treat depression and anxiety). -Really no improvement. -Still attempts 'exit-seeking'. -Gait now more shuffle than walking. -Echolalia (word repetition)-unable to formulate words otherwise. A quarterly memory care unit assessment form completed 5/19/17, 8/18/17, 11/17/17, and 2/14/18 had indicated on each assessment she: -Required a calm and structured environment to maintain comfort and dignity. -Exhibited pacing and agitation. -Was known to wander. Review of the 2/22/18 at 10:53 a.m. care conference note completed by the LSW in the IPN revealed:A care conference was held on that day. The clinical coordinator/Minimum Data Set (MDS) nurse, dietary manager, LSW were present. The resident's power of attorney was present by phone. Resident 1 was on a list to have received one-to-one activity once every week. She had lost thirteen pounds in the past six months. The physician saw her 2/13/18, and States she is tolerating her medication well. She was needing more assistance with her activities of daily living. She could not formulate words and continued to have echolalia. No concerns noted during care conference. Review of the IPN for resident 1 revealed: A 2/22/18 at 6:20 p.m. note by LPN B revealed at 5:40 p.m.: -The memory unit called me no one witnessed it and (resident 1) was on the floor bleeding on her left side, she was crying out, she could move all of her limbs freely, she was bleeding from her mouth and nose had has a huge knot on the back of her head. -She coughed up a huge clot. -The staff were unable to obtain her vital signs, because She was too worked up. -She may have fallen or she was punched by or pushed by another resident. At 6:17 p.m. she left by ambulance to the emergency room . LPN B had notified the power of attorney of the event. LPN C who was coming on duty had talked to the LSW about the event. LPN B indicated she was Sending a fax to her Dr (doctor) about the incident, and the other Dr about his behavior. The other resident was mocking her the whole time she was on the floor. Laughing at her too. A 2/23/17 at 3:59 p.m. note by the DON indicated she had contacted the hospital for an update on resident 1. She was instructed the resident had a fracture to her skull and a subdural hemorrhage. A 3/2/18 at 2:18 a.m. late entry by LPN C: Late entry for 02/23/18. Resident sent to the ER after falling and hitting her head. Hospital said has 2 bleeds in her head. There were no further entries in the IPN notes. Review of the provider's 2/22/18 at 5:30 p.m. fall report by LPN B for resident 1 revealed:The fall was not witnessed. Memory care called her. She entered memory care and found the resident on her left side. She was bleeding from her nose and mouth. There was a Huge lump the size of a golf ball on back of her occipital bone. Patient (resident) could move all 4 of her limbs freely, we then got her off the floor and sat her in a wheelchair where we tried to get vitals, but she was so shook up. Patient was then take via ambulance to (hospital name) ER. Patient did cough up a large clot and spit it out. The primary physician had been faxed at 6:00 p.m. The power of attorney had been notified at 6:00 p.m. Under the heading Was first aid administered, LPN B had written Yes/ambulance. The physician signature of notification had not been signed. A Post Fall Investigation form attached to the fall report revealed:-Resident 1 had been walking away from the supper table, To do her normal wandering at the time of the fall. -No assistive devices were in use at the time of the fall. -Resident may have hit, pushed, punched her to make her fall. -Staff members present at the time of her fall were CNA/UAP E, CNA/UAP H, and LPN B. -Is fall suspicious for abuse, mistreatment, or neglect (failure to follow care plan) of resident? had been marked Yes. -Police came here also on 2/22/18 at 6:00 p.m. -Under the heading Nursing assessment regarding the cause of the fall and interventions added to care plan to prevent further fall, including education given to resident/staff. LPN B had documented Yes - 2/22/18. -There was no documentation of any investigation of the event or interventions. -The form had been signed by LPN B, the director of nursing (DON), The Minimum Data Set (MDS) coordinator, and the administrator. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed: The 9/1/17 through 9/30/17, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-six of thirty days. On the above days the wandering behavior had: -Placed her at significant risk for twenty-six of thirty days. -Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. The 9/1/17 though 9/30/17, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behaviors. The 10/1/17 through 10/31/17 (YEAR), 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. On the above days the wandering behavior had: -Placed her at significant risk for twenty-one of thirty-one days. -Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. The 10/1/17 through 10/31/17, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. The 11/1/17 through 11/15/17, 6:00 a.m. through 6:30 p.m. entries revealed: -She had wandered in hallways or other residents' rooms for nine of fifteen days. On the above days the wandering behavior had: -Placed her at significant risk for eight of fifteen days. -Significantly intruded on the privacy or activities of others for seven of fifteen days. On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. -There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. The 11/1/17 through 11/15/17, 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. -There was no further documentation in the medical record regarding what had prompted the behavior. Review of resident 1's 11/15/17 quarterly Minimum Data Set (MDS) assessment for resident 1 revealed: She had exhibited physically aggressive behavior symptoms toward others one-to-three days per week. She had not exhibited behavioral symptoms directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds in the seven day look-back period. She had overall presence of behavioral symptoms. The above symptoms put her and others at risk for physical illness or injury. She wandered one-to-three days per week. -It significantly intruded on the privacy or activity of other residents. -It also placed the resident at significant risk of getting to a potentially dangerous place. Her behavior had worsened compared with the prior MDS assessment on 8/16/2017. Review of resident 1's 11/16/17 through 2/14/18 Behavior Detailed Entry Reports revealed: The 11/16/17 through 11/30/17, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for seven of fifteen days. On the above days the wandering behavior had: -Placed her at significant risk for seven of fifteen days. -Significantly intruded on the privacy or activities of others for seven of fifteen days. The (MONTH) 15 through (MONTH) 30,2017, 6:00 p.m. through 6:30 a.m. entries revealed she did not display any behavior. The 12/1/17 through 12/31/17, from 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-one of thirty-one days. On the above days the wandering behavior had: -Placed her at significant risk for seventeen of thirty-one days. -Significantly intruded on the privacy or activities of others for eighteen of thirty-one days. The (MONTH) (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed: -On 12/10/17 at 8:00 p.m. she had refused assistance with dressing. -On 12/11/17 at 10:00 p.m. she was Physically abusive. Hit staff. -There was no further documentation of behavior. Review of the 1/1/18 through 1/31/18, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for ten of thirty-one days. On the above days the wandering behavior had: -Placed her at significant risk for four of thirty-one days. -Significantly intruded on the privacy or activities of others for five of thirty-one days. The 1/1/18 through 1/31/18 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review of the 2/1/18 through 2/22/18, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for six of twenty-two days. On the above days the wandering behavior had: -Placed her at significant risk for three of twenty-two days. -Significantly intruded on the privacy or activities of others for three of twenty-two days. The 2/1/18 through 2/22/18, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review resident 1's interdisciplinary progress notes (IPN) revealed: An 11/24/17 LSW quarterly MDS note indicated a history of wandering and physical behavior as well as wandering and exit seeking. A 12/8/17 entry by LPN N indicated resident 1 had been grabbed on the arm by another resident (3) and was trying to shake her hand off. -When resident 3 would not let go resident 1 forcefully shoved her. Upon request for more information of the 12/8/17 incident from the DON: -There was no resident-to-resident altercation event report completed. -An investigation had not been completed to identify the cause of the above altercation. -There was no notification to the physician or either family regarding the event. -A SD DOH event report had not been completed and sent to the SD DOH. A 12/24/17 incident regarding a fall with a head injury. Review of the 12/24/17 fall report by RN O revealed CNA D had observed resident 2 threaten to back into resident 1 if she did not move. RN O had documented, Report is that he did back into her then backed into her causing her to lose her balance. Resident 1 fell hitting her head. Upon request for more information from the DON: -Resident 1's physician and power of attorney had been notified. -There was no documentation in resident 2's record of the resident-to-resident altercation. -There was no notification to resident 2's physician or family about the event. -An investigation had not been completed to identify the cause of the altercation. -A SD DOH event report had not been completed and sent to the SD DOH. A 1/15/18 note by LPN P at 5:29 p.m. indicated the resident was found on the floor with both legs in one pant leg. The fall was not witnessed. Another head injury was noted. Upon request for more information from the DON: -An investigation had not been completed to identify the cause of the above fall. -A SD DOH event report had not been completed and sent to the SD DOH. A 1/24/18 note by RN O at 9:48 p.m. indicated the resident had a fall at 3:15 p.m. Caused by aggressive behavior of another resident. -Resident 1 received another head injury after being pushed by resident 2. -The LSW was made aware of verbal and physical aggression of the other resident. Upon request for more information from the DON: -A fall report had been completed for resident 1. -Resident 1's physician and power of attorney had been notified. -An resident-to-resident altercation report had not been completed for resident 2. -There was no notification to resident 2's physician or family about the event. -An investigation had not been completed to identify the cause of the above altercation. -A SD DOH event report had not been completed and sent to the SD DOH. Two other resident-to-resident altercations had occurred between residents 1 and 2 that were not documented in resident 1's medical record. Those events were recorded in resident 2's behavior tracking record: On 1/28/18 CNA D had documented resident 2 hit resident 1 in the back. Upon request for more information from the DON: -A resident-to-resident report had not been completed for residents 1 or 2. -Residents' 1 and 2's physicians and families or power of attorney had not been notified. -An investigation had not been completed to identify the cause of the altercations. -SD DOH event reports had not been completed and sent to the SD DOH. On 1/31/18 CNA G had documented resident 2 hit resident 1 in the left upper chest shoulder, witness by (CNA K) and housekeeper and he was mocking (resident 1), making crying sound after hitting her. Upon request for more information from the DON: -Resident-to-resident reports had not been completed for residents 1 and 2. -Residents' 1 and 2's physicians' and family or power of attorney had not been notified. -An investigation had not been completed to identify the cause of the altercation. -SD DOH event reports had not been completed and sent to the SD DOH. Review of resident 1's 2/14/18 annual MDS assessment revealed: She displayed no physically or verbally aggressive behavior symptoms toward others in the seven day look-back period. No behavioral symptoms directed toward others such as	2020-09-01
161	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	609	E	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to: Ensure the South Dakota Department of Health had been notified of reportable incidents for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment. A thorough investigation had been completed for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired with reportable incidents. Findings include: 1. Review of resident 1and 2's closed records and residents 3, 4, and 5's active medical records and investigation reports revealed: The residents had been subject to falls and resident-to-resident altercations. The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). All reviewed events had not been thoroughly investigated to: -Discover the cause of the event. -Implement safeguards to prevent further potential abuse. 2. Review of the provider's 8/17/17 Care Plans - Comprehensive policy and procedures revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: -a. Incorporate identified problem areas; -b. Incorporate risk factors associated with identified problems; -d. Reflect the resident's expressed wishes regarding care and treatment goals; -g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: -a. When there has been a significant change in the resident's condition/ -b. When the desired outcome is not met; -d. At least quarterly. Review of the provider's 6/1/16 Care Planning - Interdisciplinary Team policy and procedures revealed: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: -a. The resident's Attending Physician; -b. The Registered Nurse who has responsibility for the resident; -d. The Social Services Worker responsible for the resident; -e. The Activity Director/Coordinator; -h. The Director of Nursing (as applicable); -i. The Charge Nurse responsible for resident care; -j. Nursing Assistants responsible for the resident's care; Review of the provider's (MONTH) (YEAR) Abuse/Neglect/Exploitation Investigations policy revealed: All reports of resident abuse, neglect, exploitation and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect exploitation or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The individual conducting the investigation will, as a minimum: -a. Review the competed documentation forms; -b. Review the resident's medical record to determine events leading up to the incident; -c. Interview the person(s) reporting the incident; -d. Interview any witnesses to the incident; -e. Interview the resident (as medically appropriate ); -f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; -g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; -h. Interview the resident's roommate, family members, and visitors; -i. Interview other residents to whom the accused employee provides care or services; and -j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: -a. Each interview will be conducted separately and in a private location; -b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process. 5. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. 6. The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. 7. Should the ombudsman decline the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 8. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 9. Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. 10. The individual in charge of the investigation will consult daily with the Administrator concerning the progress/findings of the investigation. 11. The Administrator will keep the resident and his/her representative informed of the progress of the investigation. 12. The results of the investigation will be recorded on approved documentation forms. 13. The investigator will give a copy of the completed documentation to the Administrator within 5 working days of the reported incident. 14. The Administrator will inform the resident and his/her representative of the results of the investigation and corrective action taken within 5 days of the completion of the investigation. 15. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. 16. Should the investigation reveal that a false report was made/filed, the investigation will cease. Residents, family members, ombudsmen, state agencies, etc., will be notified of the findings. 17. Inquiries concerning abuse, neglect and exploitation reporting and investigation should be referred to the Administrator or the Director of Nursing Services. Review of the provider's (MONTH) (YEAR) Abuse, Neglect and Exploitation-Clinical Protocol policy revealed: 1. The nurse will assess the individual and document related findings. Assessment data will include: -a. Injury assessment. -b. All current medications. -d. Vital signs. -e. Behavior over last 24 hours. -g. All active diagnoses. 2. The nurse will report findings to the physician. 3. As part of the initial assessment, the physician will help identify individuals who have a history of being abused, neglected, or exploited. 4. The physician and staff will help identify risk factors for abuse within the facility. 5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect. Review of the provider's (MONTH) (YEAR) Reporting Abuse to State Agencies and Other Entities/Individuals policy revealed: All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. 1. Should a suspected crime or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and/or written) of such incident: -a. The South Dakota State Department of Health. 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident using the 5-Working Day Investigation Report. Review of the provider's undated Resident-to-Resident Altercations policy revealed: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to Social Services, the Director of Nursing Services and to the Administrator. 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitor, or to the staff. Occurrences of such incidents shall be promptly reported to Social Services, Director of Nursing Services, and to the Administrator. 2. If two residents are involved in an altercation, staff will: -a. Separate the residents, and institute measures to calm the situation; -b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; -c. Notify each resident's representative (sponsor) and Attending Physician of the incident; -d. Review the events with Social Services and Director of Nursing, including interventions to try to prevent additional incidents; -e. Consult with the Attending Physician to identify treatable conditions such as acute [MEDICAL CONDITION] that may have caused or contributed to the problem; -f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; -g. Document in the resident's clinical record all interventions and their effectiveness; -h. Consult psychiatric services as needed for assistance in assessing the resident. -i. Complete an Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; -j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; -k. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. Review of the provider's (MONTH) (YEAR) Charting and Documentation policy revealed: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 3. All incidents, accidents, or changes in the resident's condition must be recorded. 7. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: -a. The date and time the procedure/treatment was provided; -c. The assessment data and/or any unusual findings obtained during the procedure/treatment; -f. Notification of family, physician or other staff, if indicated; -g. The signature and title of the individual documenting. Refer to F600, F610, F657, F658, F726, F744, F745, and F842.	2020-09-01
162	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	610	H	1	0	Z0T511	> Based on record review, interview, and policy review, the provider failed to ensure a thorough investigation had been completed and documented for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired and had been subject to resident-to-resident altercations. Findings include: 1. Review of resident 1, 2, 3, 4, and 5's medical records revealed: They had been subject to resident-to-resident altercations. Thorough investigations had not been documented and maintained. *The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). Refer to F600, F609, F657, F658, F726, F744, F745, and F842.	2020-09-01
163	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	657	E	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to ensure care plans were updated to reflect individual needs and interventions for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: 1. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed:For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-six of thirty days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-six of thirty days. --Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behaviors. For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-one of thirty-one days. --Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. For (MONTH) 1 through (MONTH) 15, (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for nine of fifteen days. Of those days the wandering behavior had: --Significantly intruded on the privacy or activities of others for nine of fifteen days. -On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. --There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. -The (MONTH) 1 to 15 from 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. --There was no further documentation in the medical record regarding what had prompted the behavior. Review of resident 1's 11/15/17 quarterly Minimum Data Set (MDS) assessment revealed: She had exhibited physically aggressive behavior symptoms toward others one to three days per week. She had not exhibited behavioral symptoms not directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds in the seven day look-back period. She had overall presence of behavioral symptoms. Those symptoms put her at risk for physical illness or injury. Those symptoms put other residents at risk for physical injury. She wandered one to three days per week. That wandering significantly intruded on the privacy or activity of other residents. Wandering also placed the resident at significant risk of getting into a potentially dangerous place. Her behavior had worsened compared to the prior MDS assessment. For 11/16/17 through 2/14/18: -The (MONTH) 16 through (MONTH) 30, (YEAR): --6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for seven of fifteen days. Of those days the wandering behavior had: --Placed her at significant risk for seven of fifteen days. --Significantly intruded on the privacy or activities of others for seven of fifteen days. -The (MONTH) 15 through (MONTH) 30,2017 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-one of thirty-one days. -Of those days the wandering behavior had: --Placed her at significant risk for seventeen of thirty-one days. --Significantly intruded on the privacy or activities of others for eighteen of thirty-one days. -The (MONTH) (YEAR), 6:00 p.m. through 6:30 a.m. entries revealed: --On 12/10/17 at 8:00 p.m. she had refused assistance with dressing. --On 12/11/17 at 10:00 p.m. she was Physically abusive. Hit staff. -There was no further documentation of behavior in December. For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for ten of thirty-one days. -Of those days the wandering behavior had: --Placed her at significant risk for four of thirty-one days. --Significantly intruded on the privacy or activities of others for five of thirty-one days. -The (MONTH) (YEAR), 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. For (MONTH) 1 through 22, (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for six of twenty-two days. -Of those days the wandering behavior had: --Placed her at significant risk for three of twenty-two days. --Significantly intruded on the privacy or activities of others for three of twenty-two days. -The (MONTH) 1 through 22 (YEAR), 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review of her interdisciplinary progress notes (IPN) revealed: An 11/24/17 LSW quarterly MDS note indicated a history of wandering and physical behavior as well as wandering and exit seeking. A 12/8/17 note by LPN N indicated resident 1 had been grabbed on the arm by another resident (3) and was trying to shake her hand off. When the other resident would not let go she forcefully shoved the other resident. A 12/24/17 incident regarding a fall with a head injury. Review of the 12/24/17 fall report by registered nurse (RN) O revealed the CNA D had observed resident 2 threaten to back into resident 1 if she did not move. RN O documented, Report is that he did back into her then backed into her causing her to lose her balance. Resident 1 fell , hitting her head. A 1/15/18 note by LPN P at 5:29 p.m. indicated the resident was found on the floor with both legs in one pant leg. Another head injury was noted. A 1/24/18 note by RN O at 9:48 p.m. indicated the resident had a fall at 3:15 p.m. Caused by aggressive behavior of another resident. -Resident 1 received another head injury after being pushed by resident 2. The LSW was made aware of verbal and physical aggression of the other resident. Two other resident-to-resident altercations occurred between residents 1 and 2 that were not documented in resident 1's medical record. Those events were recorded in resident 2's behavior tracking record:On 1/28/18 CNA D had documented resident 2 hit resident 1 in the back and resident 3 in the chest. On 1/31/18 CNA G had documented resident 2 hit resident 1 in the left upper chest shoulder, witness by (CNA K) and housekeeper and he was mocking (resident 1), making crying sound after hitting her. Review of resident 1's 2/14/18 annual MDS assessment revealed: She displayed no physically or verbally aggressive behavior symptoms toward others in the seven day look-back period. No behavioral symptoms not directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds had been exhibited in the seven day look-back period. She had no overall presence of behavioral symptoms. No behavioral symptoms had been acknowledged to have a negative impact on herself or others. She rejected care one to three days in the seven day look-back period. She wandered one to three days per week. That wandering significantly intruded on the privacy or activity of other residents. Wandering also placed the resident at significant risk of getting into a potentially dangerous place. Her behavior had remained the same compared to the prior MDS assessment on 11/15/17. Further review of resident 1's IPN and interview with LPN B revealed: On 2/21/18 at 6:05 p.m. LPN B documented, Patient (resident) was struck by another resident, in the chest she is fine no marks or bruising so far, made her nervous. Interview on 3/8/18 at 1:00 p.m. with LPN B revealed she did not know who had struck resident 1, nor when the event had occurred. Interview on 3/8/18 at 1:07 p.m. with CNA G revealed she had witnessed resident 2 punch resident 1 in the chest. -CNAs G and D placed her in a chair and called LPN B to come check her. No reports had been completed at that time. On 2/22/18 at 10:53 a.m. the LSW documented a care conference was held with the LSW, RN clinical coordinator/MDS coordinator, dietary manager, and resident 1's power of attorney (attended by phone). The LSW had documented: -She was on a one-to-one list once weekly for activities. -She had lost thirteen pounds in six months. -The primary physician saw her on 2/13/18 and stated she was tolerating her medication well. -She was requiring more assistance with her activities of daily living. -She was unable to formulate words and continued with echolalia. -There were no concerns noted during the conference. There was no documentation by the IDT members of the falls, head injuries, or numerous episodes of physical aggression and mocking toward resident 1 by resident 2. Review of resident 1's 1/16/17 wandering care plan revealed:She frequently wandered. Her goals were she: -Would not wander out of the facility. -Would not intrude on or endanger others. Interventions included: -To maintain a safe environment. -To prompt activity attendance daily to keep her occupied. -Staff were to observe her location and provide safety. A 1/16/17 Fall care plan revealed she was at risk for falls. Her goal was for no falls. Interventions included: -She would receive supervision with transfers, locomotion, and walking. -Staff were to prompt her to ask for assistance. -Prompt her to attend activities that did not put her at risk for falls. -Safety training and education as needed. -Provide a safe environment. -Frequent observation. Resident 1's care plan had not addressed or been updated to address interventions regarding: Falls with head injuries. Pacing as acknowledged by the primary physician. Episodes of physical behavior directed toward staff. The episode of physical aggressive behavior toward resident 3. Multiple episodes of verbal and physical aggression by resident 2 toward resident 1. Echolalia and disruptive sounds that reportedly placed her at risk of resident 2's aggression. Review of the undated pocket care plan utilized by the direct care staff on the memory unit at the time resident 1 had resided there revealed: Fall risk. Independent with walking. Wander device on. Make sure she has on non-skid foot wear. There was no mention of the concerns below, or any interventions for her: -Aggressive episode with resident 3. -Wandering on the unit and frequent intrusions in other residents rooms. -Echolalia and repeated verbal vocalizations and the impact it might have on other residents. -Her frequent falls and head injuries as a result of physical aggression by another resident. 2. Review of resident 2's medical record revealed: A 9/8/17 admitted . He resided on the MCU. [DIAGNOSES REDACTED]. Was on the antipsychotic medication [MEDICATION NAME]. Review of the 9/8/17 admission Minimum Data Set (MDS) assessment for resident 2 revealed: A Brief Interview for Mental Status (BIMS) score had been a four. A score of zero through seven meant his cognition was severely impaired. No physical and verbal behaviors were identified. Wandering occurred four to six days but less than daily. The activity preferences that were marked very important to him were to: -Listen to music he liked. -Keep up with the news. -Go outside to get fresh air when the weather was good. -Participate in religious services or practices. Review of resident 2's IPN by the social worker (SW) revealed: On 9/21/17 he documented an admission social service note that revealed:. -(Resident name) is alert with short and long term memory impairments requiring cueing and supervision. -He is able to make his needs known and some decisions by himself. -Family makes larger important decisions. -He scored a 4/15 on his BIMS suggesting cognition is severely impaired. -(Resident name) has a [DIAGNOSES REDACTED]. -(Resident name) was able to complete the PHQ-9 assessment; he scored a 0/27 indicating no depression concerns at this time. -He is very social and likes to visit with whoever will visit with him. -Wandering behavior noted during look back period. -His wife is PO[NAME] -Requests to be asked about going home on comprehensive assessments only. -Care plan written. -Review face sheet, history and physical, nurses' notes, progress notes, medication list, behavior log, resident assessments and per staff observation. On 10/11/17 the SW had documented a care conference note that revealed: Care conference held 10/4/17. -LSW, RN case manager, dietary manager, and (wife's name) were present. We discussed how resident 2 was transitioning and how well he was doing. -We did speak about how he does sometimes sundown during the late afternoon. -(Wife's name) states he has been doing that for some time. -She also states that he gets agitated when she visits him. -She does try to limit her time with (resident 2 name) to prevent him from becoming to agitated. She did request that he be brought out of the secured unit to attend large activities such as entertainers or parties. -Activities department was notified of her request. -No new concerns noted at this time. On 12/5/17 the SW had documented a social services quarterly MDS note that revealed: (Resident name) is alert with short and long term memory impairments requiring cueing and supervision. He is able to make his needs known and some decisions by himself. Family makes larger important decisions. He scored a 5/15 on his BIMS suggesting cognition is severely impaired. (Resident name) has a [DIAGNOSES REDACTED]. (Resident name) was able to complete the PHQ-9 assessment; he scored a 0/27 indicating no depression concerns at this time. -He is very social and likes to visit with whoever will visit with him. -Wandering behavior noted during look back period. -His wife is PO[NAME] -Requests to be asked about going home on comprehensive assessments only. Care plan reviewed/updated. Reviewed face sheet, history and physical, nurses' notes, progress notes, medication list, behavior log, resident assessments, and per staff observation. On 12/13/17 the SW had documented a care conference note that revealed: Care conference held this date. -LSW, RN case manager, dietary manager, and (wife's name) were present. We discussed (resident's name)food preferences and his intake. We discussed that he liked canned fruit, French toast, bacon, cereal, and chocolate ensure. -He is also on a finger food diet which allows him to be more independent with dining. He has lost twenty plus pounds. (Resident's name) did have a week when he did mention suicide and it was the week he had his [MEDICATION NAME] decreased. -His [MEDICATION NAME] has since been increased. No further concerns. It was also discussed that he loves attending musical activities. No other concerns discussed besides his weight loss. Review of resident 2's IPN by the activity director revealed: On 9/18/17 she did an interview with the resident. -He found it important to take care of his personal belongings, have a shower, and family involved in discussions about his care. -He enjoys listening to country western music, keep up with the news, go outside when the weather is good, and participate in religious activities. On 12/5/17 she did an interview with the staff. -He found it important to chose his clothing, have snacks between meals, and have his wife involved in discussions about his care. -He enjoys doing things with groups of people such as going to parties, listening to music/entertainers, going outdoors, and being involved in religious activities. -He is in the MCU but participated outside of the unit often. -His wife also visits often. -He is on the one on one list for at least once a week for activities visits where he enjoys walking, talking, music, and dancing. -Care plan reviewed. There was no revision date to the problem, goal, and interventions to reflect those activities desired by the resident. Review of resident 2's 9/11/17 initial activities evaluation revealed: His current interests were religious services, religious studies, and walking. Frequency of Activities: Not sure was checked. Other comments: Resident has Alzheimers and was unable to answer any of my questions. Review of resident 2's activities flow sheet from 1/1/18 through 2/22/18 revealed: January (YEAR): -Bingo was documented five times. -Religious event was documented five times. -Craft event was documented two times. -Music and entertainment was documented one time. -Activity cart was documented one time. -One-to-one/reminisce was documented three times. -There were fifteen out of thirty-one days activities had not occurred. February (YEAR): -Bingo was documented five times. -Religious event was documented zero times. -Pastor visit was documented one time. -Arts/Crafts/Coloring was documented one time. -Music and entertainment was documented three times. -One-to-one/reminisce was documented three times. -Outside Memory Lane, other was documented two times. -There were ten out of twenty-two days activities had not occurred. Review of the One on ones and memory care individualized activities per resident flow sheet revealed resident 2 was to have conversation, walking, talking, music, religious (devotions/rosary), and outdoors when nice. Review of resident 2's 9/18/17 activity care plan revealed: Problem: Resident finds it important to do his favorite activities both in and outside of the memory care unit. Goal: Resident will be involved in activities of interest such as going outdoors, listening to music, and participating in religious activities. Interventions: Provide resident with activities calendar and remind of scheduled activities. -Encourage resident participation in activities of interest. -Respect residents right to refuse. -Offer one on one activities visits if resident declines to participate for a prolonged period of time. There was not any information regarding his preferences, likes, or past likes. Review of resident 2's 9/18/17 wandering care plan revealed: Problem: Resident wanders throughout secured memory care unit. Goals: Resident will not wander out of facility. -Will have no injuries related to wandering. -Will not intrude on or endanger others. Interventions: Maintain safe, clutter free environment. -Provide orientation to facility layout and room as needed. -Redirect when wandering. -Ensure resident wears appropriate, well fitting footwear minimize the risk of slipping. -Prompt activity attendance daily to keep resident occupied. -Observe resident's location to ensure safety. No revision and/or updates were made to his problem, goal, and interventions. No problem, goal, and interventions were documented for agitation stated on his care plan. No problem, goal, and interventions were documented for aggressive behavior stated on his care plan. Review of resident 2's 10/5/17 [MEDICAL CONDITION] care plan revealed: Problem: Resident requires the use of a [MEDICAL CONDITION] medication. Goals: Will be at lowest therapeutic dose of medication through next review date. -Will have reduction is symptoms noted through next review date. Interventions: MD consult as needed. -Will monitor behavior. -Activities to evaluate for interests and skills/abilities. -Administer medication as ordered by MD and assess for effectiveness and side effects. -Treat side effects per MD order should they occur. -Physician/Pharmacist will work together to ensure resident is on lowest therapeutic dose. There were physician orders [REDACTED]. -On 9/8/17 he was admitted and was on [MEDICATION NAME] 1 mg daily for mood stabilization. -On 10/16/17 he was discontinued on the [MEDICATION NAME]. -On 2/2/18 he was started on [MEDICATION NAME] 2.5 mg daily for aggression. -On 2/8/18 the [MEDICATION NAME] was ordered to be increased to 5 mg daily for aggression starting 2/9/18. No revisions and/or updates were made to his problem, goal, and interventions. Review of the undated pocket care plan utilized by the direct care staff on the memory unit at the time resident 2 had resided there revealed: He liked to swear. He ambulated independently. He was on a regular diet. No information on interventions for activities for him. No types of distractions and interventions for agitation and/or aggressive behaviors. Interview on 3/7/18 at 11:11 a.m. with the LSW regarding resident 2's care planning process revealed he: Was aware of his aggressive behaviors by reports heard at stand-up meetings. Was aware of his verbally aggressive behaviors toward spouse. -She had reported to him the resident had accused her of drinking and/or having an affair. Was aware of resident 2 pushing other residents in the memory care unit. He agreed his care plan and My pocket care plan: -Did not address his behaviors on the care plan. -Did not address his depression/mood on the care plan. -Were not individualized for him. Interview on 3/8/18 at 11:14 a.m. with the activity director regarding resident 2 revealed: He enjoyed conversation and was very chatty. He liked to go outside when the weather was nice. He enjoyed coffee and cookies. He went out of MCU for rosary on Wednesdays and for church on Sundays. He went out of MCU with his spouse for music and entertainment events. She agreed his care plan and My pocket care plan were not individualized for him. 3. Review of resident 3's medical record revealed: An 8/8/17 admitted . She resided on the MCU. [DIAGNOSES REDACTED]. Was on the antipyschotic medication [MEDICATION NAME]. Review of the 2/5/18 quarterly MDS assessment revealed: BIMS score of 99 indicating she was unable to be interviewed. Ability to understand and make self understood was coded sometimes understands. Had inattention and disorganized thinking. Being short-tempered, easily annoyed was coded as occurring for several days. had a history of [REDACTED]. Review of the quarterly MCU assessment for 11/8/17 and 2/8/18 for resident 3 revealed it had been coded yes for exhibits pacing, agitation and/or aggressive behavior, and wanders. Review of resident 3's IPN notes from 12/6/17 through 3/6/18 revealed on: 12/8/17: Grabbing the arm of another resident when the other resident was trying to shake it off and (resident 3) would not let go. The other resident forcefully shoved (resident 3) once she had had enough. 12/11/17: Has been pulling on another resident most of the shift, resident does not re-direct easily and one-on-one was not successful. This writer had to physically place her body in between residents before (resident) would walk away. As soon as this writer moved away, (resident) continued to pull on other resident. 12/18/17: Pulling on other residents, attempting to have resident's ambulate w/her. Staff intervened several times. 1/5/18: Notified that CNA head a loud noise in the hallway and upon investigation noted that resident was getting up off the floor holding the back of her head. Resident restless, agitated and would not sit still for examination. Did not (get) a 3x3 hematoma to the back of resident's head. 1/5/18: Has been grabbing at resident's and staff throughout the day. Redirection not effective. Staff has had to intervene between resident grabbing at other resident's on several occasions. Attempted to redirect bu unsuccessful. Grabs at other resident hands, arms and follows them around. Another resident did swat at her arms to get away from even as staff member was attempting to break resident up. 1/8/18: Up pacing in the halls tries to help everyone whether they want help or not will grab other residents and try to pull them down the hallways no s/s no noted increased pain. 1/30/18: Received a skin teat (tear) to (R) lower forearm. Another resident was reaching for her arm and when she pulled away causing a 4x3.2 cm (centimeter) skin tear/bruise to area. 2/14/18: Category:Nursing Note. Refer to care plan for goals and interventions to assist with providing resident's care. Review of resident 3's behavior flow sheets from 12/1/17 through 3/7/18 revealed on: 12/10/17 at 9:16 a.m.: Physically abusive. Grabs other residents arms, pulls and twists. 1/5/16 at 9:05 p.m.: Physically abusive. Physical altercation with another resident. 1/6/18 at 5:13 p.m.: Physically abusive. Grabbing and hitting, squeezing residents hands, pulling staff and residents. 1/29/18 at 9:41 p.m.: Physically abusive. Grabbing residents. 3/3/18 at 4:22 p.m.: Socially inappropriate. Grabbing and holding on to staff and residents. Review of resident 3's undated and unsigned activities evaluation revealed: Her current interests were animals/pets, family/friend visit, music, and walking. Time for activities was coded morning and afternoon. Other comments: Especially enjoys family visits. Outdoors. Review of resident 3's activities flow sheet from (MONTH) (YEAR) through (MONTH) 7, (YEAR) revealed: December (YEAR): -One-to-one was done weekly. -Art/crafts were documented five times. -Social event was documented one time. -Games was documented two times. -Walk was documented one time. -There were eighteen out of thirty-one days activities had not occurred. January (YEAR): -One-to-one activity had been documented three out of five weeks as occurring. -Social event was documented one time. -Activity cart was documented one time. -Manicure/beauty shop was documented one time. -Arts/crafts/coloring was documented one time. -There were twenty-three out of thirty-one days activities had not occurred. February (YEAR): -One-to-one was documented four out of five weeks as occurring. -Art/crafts/coloring was documented four times. -Exercise/movement/cycle was documented one time. -Manicure/beauty shop was documented one time. -Activity cart was documented one time. -There were fourteen out of twenty-eight days activities had not occurred. March 1 through 7, (YEAR): -One-to-one had not occurred the week of (MONTH) 25 through (MONTH) 3, (YEAR). -There were two out of seven days activities had not occurred. Review of resident 3's IPN note for 2/6/18 by the activity director revealed She is in the memory care unit and on the activities one on one list for at least once a week where she enjoys walking, talking and going outdoors if the weather is nice. Care plan reviewed. Review of resident 3's 8/18/17 care plan revealed: Problem: Wanders throughout secured memory care unit. -Goal: Will not intrude on or endanger others. -Interventions: Redirect when wondering. Prompt activity attendance daily to keep resident occupied. Problem: Needs encouragement to join activities in the memory care unit. -Goal: Will join in activities of interest. -Interventions: Provide with activities calendar and orient to activities in memory care unit. Continue one--on-one visits with resident having conversations, walking, and going outdoors. There were no problems, goals, or interventions for behaviors. There was not any information regarding her preferences, likes, or past likes. Review of the undated My pocket care plan memory care revealed no information on interventions for behaviors or activities for resident 3. Review of the One-on-ones and memory care individualized activities per resident flow sheet revealed resident 3 was to have walk and talk, and music. 4. Review of resident 4's medical record revealed: An admission date of [DATE]. She resided on the MCU. [DIAGNOSES REDACTED]. Review of resident 4's 12/21/17 quarterly MDS assessment revealed: BIMS score of 99 indicating she was unable to be interviewed. Was able to understand others. Was able to express her needs and wants. Wandering had been coded as Significant risk of getting to (into) a potentially dangerous place and intrude on the privacy or activities of others. She had displayed being short-tempered and easily annoyed. She had received an antipsychotic, antianxiety, and antidepressant medication. Review of resident 4's quarterly MCU assessment for 4/29/17, 6/29/17, 9/27/17, and 12/26/17 revealed: She required a calm and structured environment to maintain comfort and dignity. Was known to wander. Exhibited pacing, agitation, and/or aggressive behavior. Review of resident 4's IPN notes from 12/3/17 through 3/6/18 revealed on: 12/11/17: This writer had to remove a butter knife from resident's grip; resident picked up knife after another resident started pulling on her. This is habitual, the grabbing on this resident by another, and this resident has already shoved other resident away once before. 1/2/18: Refer to care plan for goals and interventions to assist with providing resident's care. 1/22/18: Notified by staff member that resident slapped another resident at dinner table, in the chest. Then a few minutes ago resident was arguing over a coffee mug in dining w/another resident who she had taken the coffee mug from and slapped her in her face. Staff member attempted to redirect resident from one another. Redirected easily but then begins to follow residents around unit closely again. 2/13/18: Has been crying on and off all morning. Pacing the hallways, banging on the exit doors, windows, and clinging to other resident's crying uncontrollable. 3/4/18: Crying all shift, unable to console with different attempts towards redirection. Review of resident 4's behavior flow sheets from 12/1/17 through 3/7/18 revealed on: 12/7/17 at 2:10 p.m.: Physically abusive. Shoved others. Shoved staff. Grabbing, pulling, on others. 12/7/17 at 2:11 p.m.: Verbally abusive. Cursed. Screamed at staff. Screamed at others. 12/10/17 at 8:46 a.m.: Socially inappropriate. Crying, yelling for her husband, going into other residents rooms, yelling for someone named (name). 12/10/17 at 8:06 p.m.: Socially inappropriate. Disruptive sounds. Crying excessively. 12/20/17 at 2:22 p.m.: Verbally abusive. Cursed. Excessive curing throught the day. 1/19/18 at 10:49 a.m.: Verbally abusive. Screamed at others. Cursed. 1/22/18 at 3:55 p.m. Physically abusive. Slapped (resident) in chest and (resident) in the face. 2/3/18 at 9:56 a.m.: Verbally abusive. Screamed at staff. Screamed at others. Cursed. 2/15/18 at 12:22 p.m.: Verbally abusive. Cursed. 3/1/18 at 8:42 a.m.: Verbally abusive. Cursed. Review of resident 4's undated and unsigned activities evaluation revealed her current preferences were marked for: Animals/pets. Arts/crafts. Beauty/barber. Bingo. Community outings with husband. Current events/news. Family/friend visits. Music, radio, religious services, religious studies. Social/parties. Television. Revie	2020-09-01
164	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	658	G	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure two of two closed resident records (1 and 2) who had cognitive impairment and resided on the memory care unit (MCU): Had notified the residents' (1 and 2) physicians of significant changes as required. Had provided appropriate emergency response for one of one sampled resident (1) with a fall with a major injury. Had identified, assessed and documented specific targeted behaviors for both residents. Reviewed and modified the interdisciplinary care plans to identify specific interventions to address behavioral and mood-related symptoms for both residents. Findings include: 1. Observation on 3/8/18 at 1:00 p.m. of an undated and unsigned note posted at the Warren unit nurses' station revealed: (Medical director's name) and his team DO NOT want to receive faxes!!! If it is important and needs to be addressed right away you need to call him. If it can wait, then write out a fax and put it in the medical records folder (at each nurses station) and (medical records staff name) will get it to him when he comes out that week. Observation on 3/8/18 at 1:00 p.m. of an undated Charting guidelines posted at the Warren unit nurses' station revealed: Chart any behaviors as an IPN note. If behavior needs to continue to be monitored put on pass along to chart for two to three days. Event report: front and back fully completed, call family, fax MD, IPN Note. Surveyor: 2. Review of resident 1's 2/22/18 resident transfer form had indicated: The resident's name. She was a female. Date of the transfer was 2/22/18. Payment source was Other. Under vitals at time of transfer: Could not. Too worked up. Speech and mental impairments had been checked. Additional pertinent information indicated Has dementia on locked unit. The above form had not indicated: -The name of the physician or facility transferring from. -The name of the facility transferring to. -The name of the guardian. -Her diagnoses. -The time of the injury. -Her condition at the time of the transfer. -The reason for the transfer. -A signature of the nurse providing the information. Surveyor: 3. Review of resident 2's 2/23/18 resident transfer form had indicated: The resident's name. He was a male. Date of the transfer was 2/23/18. Payment source was Other. Under vitals at the time of transfer: N/[NAME] Mental and hearing impairments had been checked. Important medical information: NKD[NAME] Under advance directives yes and copy attached had been checked. Code status: DNR. Additional pertinent information indicated, He was suspected of hurting, hitting, punching, or pushing another resident multiple times. The form had not indicated: -The name of the guardian and contact information. -[DIAGNOSES REDACTED]. -His condition at the time of the transfer. -A signature of the nurse providing the information. -The date the nurse completed the resident transfer form. 4. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding the 2/22/18 at 5:40 p.m. resident-to-resident altercation revealed she: Had not received any orientation on how to complete a hospital transfer form for resident 1. Did not receive any event report checklists and/or guidelines to follow to complete a resident-to-resident altercation. Had to call the other two night nurses working that date for directions on how to: -Contact the emergency response system. -Complete the required mandatory reporting forms. Had faxed resident 2's event report form to the primary care physician (PCP) at 6:00 p.m. Interview on 3/7/18 at 12:43 p.m. with the medical director regarding the 2/22/18 resident-to-resident altercation revealed he: Thought the MCU was an appropriate placement for resident 2. Stated resident 2's Behaviors were ramped up just recently. Had seen resident 2 on 2/2/18 for aggressive behaviors, anger and aggression, and had ordered an antipsychotic medication. Stated in his own professional opinion it was Hard to say if they should have moved resident 1, probably should of stabilized her neck with a bump to her head. Agreed it was a problem if LPN B had no formal orientation to the emergency response protocol. Assisted with writing the MCU admission criteria. Deferred to the director of nursing for the protocols on wandering, pacing, agitation, and aggressive behavior. Interview on 3/7/18 at 4:04 p.m. with the administrator and the director of nursing (DON) regarding MCU policies and protocols revealed the facility did not have: Policies and procedures for the MCU. Protocols for wandering, pacing, agitation, and aggressive behavior. Interview on 3/7/18 at 4:35 p.m. with LPN C regarding the 2/22/18, 5:40 p.m. resident-to-resident altercation revealed she had: Came on duty at 6:00 p.m. Notified the LSW and supervisor on duty at 6:00 p.m. of the event. Not notified the PCP of resident 2's continued aggressive behaviors. Felt the fax was sufficient notification to the medical director since it: -Was so late the doctor would not do anything with it. -Would be taken care of in the morning. -Stated she would call if a situation was very serious. Further interview on 3/8/18 at 2:38 p.m. with the administrator and the DON regarding immediate notification of significant changes for residents 1 and 2 revealed: LPN B had made multiple phone calls and should have known how to call the emergency response system for resident 1. LPN B or C should have notified resident 2's doctor by a phone call versus a fax. 5. Review of the provider's undated MCU admission criteria revealed: Individuals who are being considered for admission will exhibit at least two of the following characteristics: -a. Primary [DIAGNOSES REDACTED]. -b. Displays impaired judgement. -c. Requires a calm and structured environment. -d. Exhibits pacing, agitation, and/or aggressive behavior. -e. Resident is known to wander. The individual is able to participate in and benefit from consistent, daily programming in a therapeutic environment. 6. Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., (YEAR), revealed professional standards in nursing practice for: p. 316, communication includes: -Communication is the key to nurse-patient relationships and the ability to deliver patient-centered care. -Patient safety also requires effective communication among members of the health care team as patients move from one caregiver to another or from one care setting to another. pp. 356 to 358, written documentation includes: -Documentation is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record. -Nursing documentation needs to be accurate and comprehensive. -To enhance communication and promote safe patient care, document assessment findings and patient information as soon as possible after you provide care. -Record all facts. -Begin each entry with date and time and end with your signature and credentials. p. 367, incident reports includes: -When an incident occurs, document an objective description of what happened; what you observed: and the follow-up actions taken, including notification of the patient's health care provider in the patient's medical record. -Remember to evaluate and document the patient's (resident) response to the incident. p. 382, nursing assessment for falls includes: -Apply ANA (American Nurses Association) and TJC (The Joint Commission) standards of providing interventions in a safe and appropriate manner. *Evidenced based clinical practice guidelines for a post fall assessment of a witnessed suspected fall includes: -Do not move a resident who was experiencing neck pain, abnormal neurological check, altered mental status, and poor historian. -A nursing assessment should include vital signs, injuries, loss of consciousness/neuro checks, range of motion, resident activity, and resident behavior. -Communication to the MD, nursing leadership, and appropriate interdisciplinary care team members. 7. Refer to F600, F609, F610, F657, F658, F679, F726, and F745.	2020-09-01
165	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	679	F	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, interview, policy review, and job description review, the provider failed to ensure an individualized activity program had been provided for two of two sampled resident closed records (1 and 2) and three of three sampled residents (3, 4, and 5) in the memory care unit (MCU). Findings include: Surveyor: 1. Observation and interview on 3/6/18 at 3:00 p.m. in the MCU revealed certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) K sat at a table with two residents. There were two magazines on two different tables. The residents sat but were not looking through magazines or participating in other activity. Interview with CNA/UAP K at that time revealed: She mainly worked alone from 6:00 a.m. until 6:30 p.m. Maybe three times per week there was another staff member working with her from 6:00 a.m. until 2:30 p.m. An activity calendar was attached to the wall in the social area. The calendar indicated the activities for the afternoon were: -A bible study at 1:30 p.m. -Bingo at 2:30 p.m. -Coffee and snack at 2:30 p.m. -Card Club at 4:30 p.m. When questioned about the activities listed on the calendar CNA/UAP K stated the calendar was for the residents who resided outside of the memory unit. -The memory care unit residents did not follow that calendar. One or two of the memory care unit residents attended some of the off-unit activities. She stated the activity staff came to the memory unit maybe three times per week for an activity. The activity staff did provide some activity items such as [MEDICATION NAME] and paper. It was difficult for her to conduct activities alone while caring for the residents. Surveyor: 2. Observation on 3/6/18 from 4:10 p.m. through 4:15 p.m. in the MCU revealed: There were: -Four residents sitting at a table. -CNA/UAP [NAME] was sitting at the table visiting with two of the residents. -The other two residents at the table were sitting there without any staff interaction. -Two residents were sitting in chairs away from the table. -Two residents were walking down the hallway. Surveyor: 3. Random observation on 3/7/18 at 10:37 a.m. in the MCU revealed: There were: -Three residents sitting at a table with no activity participation and/or social conversation observed. -CNA K stood by resident 4. --They were singing to the song on the radio. Surveyor: 4. Observation on 3/7/18 from 3:45 p.m. through 3:58 p.m. in the MCU revealed: Resident 4 was crying and grabbing on to the surveyor's arm. Resident 3 came up to the surveyor and grabbed on to the surveyor's other arm. The television was on. Several residents were sitting by the television or by the table. -They were not engaged in an activity or conversation. Surveyor: 5. Review of resident 2's medical record revealed: A 9/8/17 admitted . He resided on the MCU. [DIAGNOSES REDACTED]. Was on the antipsychotic medication [MEDICATION NAME]. Review of the 9/8/17 admission Minimum Data Set (MDS) assessment for resident 2 revealed: A Brief Interview for Mental Status (BIMS) score had been a four. A score of zero through seven meant his cognition was severely impaired. The activity preferences that were marked very important to him were to: -Listen to music he likes. -Keep up with the news. -Go outside to get fresh air when the weather was good. -Participate in religious services or practices. Review of resident 2's 9/11/17 initial activities evaluation revealed: His current interests were religious services, religious studies, and walking. Frequency of Activities: Not sure was checked. Other comments: Resident has Alzheimers and was unable to answer any of my questions. Review of the review of resident 2's 9/18/17 care plan revealed: Problem: Resident finds it important to do his favorite activities both in and outside of the memory care unit. Goal: Resident will be involved in activities of interest such as going outdoors, listening to music, and participating in religious activities. Interventions: Provide resident with activities calendar and remind of scheduled activities. -Encourage resident participation in activities of interest. -Respect residents right to refuse. -Offer one on one activities visits if resident declines to participate for a prolonged period of time. There was not any information regarding his preferences, likes, or past likes. Review of resident 2's interdisciplinary progress notes (IPN) by the activity director revealed: On 9/18/17 she had done an interview with resident 2 and found: -It important to take care of his personal belongings, have a shower, and family involved in discussions about his care. -He enjoys listening to country western music, keep up with the news, go outside when the weather is good, and participate in religious activities. On 12/5/17 she did an interview with the staff and found: -It important to chose his clothing, have snacks between meals, and have his wife involved in discussions about his care. -He enjoys doing things with groups of people such as going to parties, listening to music/entertainers, going outdoors, and being involved in religious activities. -He is in the MCU but participated outside of the unit often. -His wife also visits often. -He is on the one on one list for at least once a week for activities visits where he enjoys walking, talking, music, and dancing. -Care plan reviewed. There was no revision date to the problem, goal, and interventions to reflect those activities desired by the resident. Review of the undated My pocket care plan memory care revealed no information on interventions for activities and behaviors for him. Review of resident 2's activities flow sheet from 1/1/18 through 2/22/18 revealed: January (YEAR): -Bingo was documented five times. -Religious event was documented five times. -Craft event was documented two times. -Music and entertainment was documented one time. -Activity cart was documented one time. -One-to-One/Reminisce was documented three times. -There were fifteen out of thirty-one days activities had not occurred. February (YEAR): -Bingo was documented five times. -Religious event was documented zero times. -Pastor Visit was documented one time. -Arts/Crafts/Coloring was documented one time. -Music and entertainment was documented three times. -One-to-One/Reminisce was documented three times. -Outside Memory Lane other was documented two times. -There were ten out of twenty-two days activities had not occurred. Review of the One on ones and memory care individualized activities per resident flow sheet revealed resident 2 was to have conversation, walking, talking, music, religious (devotions/rosary), and outdoors when nice. Interview on 3/8/18 at 11:14 a.m. with the activity director regarding resident 2 revealed: He enjoyed conversation and was very chatty. He liked to go outside when the weather was nice. He enjoyed coffee and cookies. He went out of MCU for rosary on Wednesdays and for church on Sundays. He went out of MCU with his spouse for music and entertainment events. She agreed his care plan was not individualized for him. 6. Review of resident 1's medical record revealed: She had been admitted on [DATE]. She had resided on the MCU. A 12/12/17 physician's progress note indicated: -[DIAGNOSES REDACTED]. -No longer able to even do social chatter. -She was quickly declining cognitively. -She walked with a shuffled gait, head held down. The 11/15/17 MDS assessment indicated a BIMS score of one indicating severe cognitive impairment. The 2/14/18 MDS assessment BIMS score was unlisted and indicated the resident was unable to complete the interview. Review of the 2/14/18 MDS section F indicated: An interview with resident 1 was not obtained, because she was rarely or never understood, and family/significant other were not available. A Staff Assessment of Daily and Activity Preferences indicated: -Choosing clothes to wear. -Caring for personal belongings. -Receiving a shower. -Reading books, newspapers, or magazines. -Participating in favorite activities. -Spending time outdoors. Review of resident 1's 2/15/18 Activities Evaluation revealed her current activity preferences had included: Arts and crafts. Current events. Walking. Visits from family or friends. Gardening. Reading. Religious services. Television. She preferred activities daily. A 2/16/18 Activities IPN note by the activities director revealed: She confirmed the above 2/14/18 MDS information was accurate. (Resident 1) is on the memory unit and is on the one on one (1:1) list for at least once a week where she enjoys walking and talking. The care plan was reviewed. Review of her 5/18/17 care plan revealed:She needed encouragement to attend activities. The goal was she would be encouraged to participate in activities of interest such as bingo, outings, music, crafts, and movie and popcorn. Interventions included: -She was to have been invited and prompted to attend scheduled activities. -Staff were to provide an activity calendar. -Staff were to prompt activity attendance daily to keep her occupied. -There was no indication she was to have received one-to-one (1:1) activity. Review of her undated pocket care plan revealed no activity problems or interventions had been identified. Review of her 12/3/17 through 2/22/18 Activities with Staff Detail Report for her weekly attendance record revealed: 12/3/17-12/9/17: One activity. No 1:1 activity was provided. 12/10/17-12/16/17: One activity. No 1:1 activity was provided. 12/17/17-12/23/17: One activity. No 1:1 activity was provided. 12/24/17-12/30/17: One activity. No 1:1 activity was provided. 12/31/17-1/6/18: One activity. No 1:1 activity was provided. 1/7/18-1/13/18: One activity. No 1:1 activity was provided. 1/14/18-1/20/18: One activity. No 1:1 activity was provided. 1/21/18-1/27/18: Three activities. All three activities were 1:1. 1/28/18-2/3/18: Two activities. One activity was a 1:1. 2/4/18-2/10/18: Two activities. One activity was 1:1. 2/11/18-2/17/18: Three activities. All three activities were 1:1. 2/18/18-2/22/18: Three activities. Two of the activities were 1:1. Resident 1 had been provided: Twenty activities in eighty-two days. Ten 1:1 activities in eight-two days. Interview on 3/13/18 at 9:15 a.m. with the activity coordinator regarding resident 1 revealed: She did not like to participate in group activities, because they made her more anxious and agitated. She was to have been getting 1:1 activity from the activity staff at least once weekly. When questioned if once weekly 1:1s were adequate activity for the resident who became more agitated with group activity she stated: -The activity staff had attempted to do more 1:1 activity when there was time. -Some activity staff had to take some time off, so they were sharing duties. Prior to being hired in her coordinator role there was one part-time activity aide specifically for the memory care unit. That position had been eliminated. 7. Review of resident 3's medical record revealed: An 8/8/17 admitted . She resided in the MCU. [DIAGNOSES REDACTED]. Was on the antipsychotic medication [MEDICATION NAME]. Review of the 2/5/18 quarterly MDS assessment revealed: BIMS score of 99. Ability to understand and make self understood was coded sometimes understands. Had inattention and disorganized thinking. Being short-tempered, easily annoyed was coded as occurring for several days. Review of the quarterly MCU assessment for 11/8/17 and 2/8/18 for resident 3 revealed it had been coded yes for exhibits pacing, agitation and/or aggressive behavior, and wanders. Review of resident 3's undated and unsigned activities evaluation revealed: Her current interest were animals/pets, family/friend visit, music, and walking. Time for activities was coded morning and afternoon. Other comments: Especially enjoys family visits. Outdoors. Review of resident 3's activities flow sheet from (MONTH) (YEAR) through (MONTH) 7, (YEAR) revealed: December (YEAR): -One-to-one was done weekly. -Art/crafts were documented five times. -Social event was documented one time. -Games was documented two times. -Walk was documented one time. -There were eighteen out of thirty-one days activities had not occurred. January (YEAR): -One-to-one activity had been documented three out of five weeks as occurring. -Social event was documented one time. -Activity cart was documented one time. -Manicure/beauty shop was documented one time. -Arts/crafts/coloring was documented one time. -There were twenty-three out of thirty-one days activities had not occurred. February (YEAR): -One-to-one was documented four out of five weeks as occurring. -Art/crafts/coloring was documented four times. -Exercise/movement/cycle was documented one time. -Manicure/beauty shop was documented one time. -Activity cart was documented one time. -There were fourteen out of twenty-eight days activities had not occurred. March 1 through 7, (YEAR): -One-to one had not occurred the week of (MONTH) 25 through (MONTH) 3, (YEAR). -There were two out of seven days activities had not occurred. Review of resident 3's interdisciplinary progress note for 2/6/18 by the activity director revealed: She is in the memory care unit and on the activities one on one list for at least once a week where she enjoys walking, talking and going outdoors if the weather is nice. Care plan reviewed. Review of resident 3's 8/18/17 care plan revealed: Problem: Wanders throughout secured memory care unit. -Goal: Will not intrude on or endanger others. -Interventions: Redirect when wondering. Prompt activity attendance daily to keep resident occupied. Problem: Needs encouragement to join activities in the memory care unit. -Goal: Will join in activities of interest. -Interventions: Provide with activities calendar and orient to activities in memory care unit. Continue one on one visits with resident having conversations, walking, and going outdoors. There was not any information regarding her preferences, likes, or past likes. Review of the undated My pocket care plan memory care revealed no information on interventions for behaviors or activities for resident 3. Review of the One on ones and memory care individualized activities per resident flow sheet revealed resident 3 was to have walk and talk, and music. 8. Review of resident 4's medical record revealed: An admission date of [DATE]. She resided on the MCU. [DIAGNOSES REDACTED]. Review of resident 4's 12/21/17 quarterly MDS assessment revealed: BIMS score of 99. Was able to understand others. Was able to express her needs and wants. Wandering had been coded as Significant risk of getting to (into) a potentially dangerous place and intrude on the privacy or activities of others. She had displayed being short-tempered and easily annoyed. She had received an antipsychotic, antianxiety, and antidepressant medication. Review of resident 4's quarterly MCU assessment for 4/29/17, 6/29/17, 9/27/17, and 12/26/17 revealed: She required a calm and structured environment to maintain comfort and dignity. Was known to wander. Exhibited pacing, agitation, and/or aggressive behavior. Review of resident 4's undated and unsigned activities evaluation revealed her current preferences were marked for: Animals/pets. Arts/crafts. Beauty/barber. Bingo. Community outings with husband. Current events/news. Family/friend visits. Music, radio, religious services, religious studies. Social/parties. Television. Review of resident 4's activities flow sheet from (MONTH) (YEAR) through (MONTH) 7, (YEAR) revealed: December (YEAR): -One-to-one activities had been documented three out of five weeks as occurred. -There were eighteen out of thirty-one days activities had not occurred. January (YEAR): -One-to-one activities had been documented two out of five weeks as occurred. -There were twenty-four out of thirty-one days activities had not occurred. February (YEAR): -One-to-one activities had been documented three out of four weeks as occurred. -There were thirteen out of twenty-eight days activities had not occurred. March 1 through 7, (YEAR): -One-to-one activity had occurred twice. -There were two out of seven days activities had not occurred. Review of resident 4's 4/17/17 care plan revealed: Problem: Becomes very distraught and confused, asking about her husband, during any kind of activity. -Goal: Will be involved in activities of interest such as gerobics and music both in the memory care unit and occasionally in the main activity area. -Interventions: --Provide with an activities calendar and orient to areas. --Encourage participation. --Continue one-on-one visits in the MCU. There were no problems, goals, or interventions regarding her crying, intrusiveness, wandering, or other behaviors on the care plan. Review of the undated My Pocket Care Plan Memory Lane revealed no interventions or activities for resident 4. 9. Review of resident 5's medical record revealed: An admission date of [DATE]. [DIAGNOSES REDACTED]. Review of resident 5's quarterly MCU assessment for 6/19/17, 8/21/17, 11/20/17, and 2/15/18 revealed: He required a calm and structured environment to maintain comfort and dignity. He was known to wander. Review of resident 5's interdisciplinary progress note from 2/16/18 revealed: Activities: -Enjoys flipping through magazines and newspapers and also enjoys going outdoors when the weather is good. -Is on the one on one list for at least once a week where he enjoys reading and outdoors. -Care plan reviewed. Review of resident 5's undated and unsigned activities evaluation revealed his current preferences were marked for: Animals/pets. Current events/news. Family/friend visits. Movies. Music. Radio. Religious services. Religious studies. Television. Sports-sometimes football. Review of resident 5's activities flow sheet from (MONTH) 8, (YEAR) through (MONTH) 2, (YEAR) revealed: 12/8/17 through 12/31/17: -One-to-ones had not occurred. -There were nineteen out of twenty-three days activities had not occurred. January (YEAR): -One-to-ones had occurred one out of five weeks. -There were twenty-six out of thirty-one days activities had not occurred. February (YEAR): -One-to ones had occurred one out of five weeks. -There were twenty-six out of twenty-eight days activities had not occurred. March 1 through 2, (YEAR) activities had occurred once. Review of the undated My Pocket Care Plan Memory Lane revealed no interventions or activities for resident 5 Review of resident 5's 4/13/17 care plan revealed: Problem: Does not find it very important to be involved in activities in the memory care unit. -Goals: Will be involved in activities of interest such as animal visits and reading magazines in the memory care unit. -Interventions: --Provide with activities calendar and remind of scheduled activities. --Encourage resident to participate in activities. Problem: Confusion, alteration in thought process related to dementia. -Goals: Will maintain independence as evidenced by ability to recall location of activity calendar and attending activities of choice daily. -Interventions: --Orient resident to location of activity calendar, provide a calendar of activities. --Encourage family to provide objects from home to provide a greater sense of security. --Encourage participation in small group activities that promote choice, self expression, and/or responsibility. --Provide quiet, calm environment if resident was agitated. There were no problems, goals, or interventions related to his behaviors. 10. Interview on 3/7/18 at 8:39 a.m. with CNA/UAP [NAME] regarding activities on the MCU revealed: The activity staff came to the MCU but not everyday. They would do one-to-ones, read, or make art/craft projects. The ladies on MCU liked to fold towels. Most of the residents liked to nap after breakfast. The CNAs would do small activities that consisted of painting nails or coloring. Resident 2 had gone to the main floor with an escort to play Bingo. Interview on 3/8/18 at 9:45 a.m. with CNA/UAP D regarding activities on the MCU revealed: There used to be an activity aide who worked on the MCU. They had not received any direction from the QAC (qualified activity coordinator) on what activities to do with the residents. The activity calendar was the same in the MCU as it was on Warren, Central, and East wings. A lot of times the MCU did not do the activities. She has provided activities for the MCU residents that consisted of painted their fingernails, puzzles, coloring, put on a movie, or music. Surveyor: Interview on 3/13/18 at 10:46 a.m. with the director of nursing (DON) regarding activities revealed: They had lost an activity aide who had worked four hours a day on the MCU. Most days there was only one person on the MCU. Interview on 3/8/18 at 10:48 a.m. with the activity director regarding the MCU activities program revealed: She worked full time. She had two other activity assistants in her department. The three alternated working every third weekend and holiday. On weekends the activity person would help with lunch. Activities could change throughout the day. There was a different activity calendar for the MCU from the main nursing home. They did one-to-one visits with the MCU residents each week. The activity staff charted on each activity. She had asked the CNAs on the MCU to document the activities, but they were not consistent in doing so. Surveyor: Interview on 3/8/18 at 10:48 a.m. with the activity director revealed: She usually went to the MCA in the morning and early afternoon. No one-to-one activities in the MCU yesterday due to being short staffed. No scheduled activities in the MCU today due to being short staffed. She had not provided training and education to the MCU staff to: -Initiate resident activities. -Document activities in the care tracker. She did not see a strong activity program in MCU. She participated in the Quality Assurance Performance Improvement (QAPI) meetings. -She presented the residents activity participation rate. -She reviewed the residents who fell , and the number of activities they were doing. Surveyor: 10. Review of the (MONTH) (YEAR) through (MONTH) 7, (YEAR) Memory Care Activities calendar revealed there were scheduled activities every day. Review of the provider's 3/24/17 Activity Assessment policy revealed: In order to promote the physical, mental, and psychosocial well-being of residents, an activity assessment is conducted and maintained for each resident. 4. The activity assessment is used to develop an individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest. 5. Each resident's activities care plan shall relate to his/her comprehensive assessment and should reflect his/her individual needs. Review of the provider's 3/24/17 Activity Department In-Service Education policy revealed: The Activity Department provides in-service education and training at least annually regarding the purpose, function, and need for resident activities. 2. Newly hired staff are oriented to the role of the Activity Department and the value of activities to the residents' quality of life. Review of the provider's (MONTH) (YEAR) Programming for Residents with Cognitive Impairments and Other Special Needs policy revealed: Activity programs are provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive, and emotional health. The facility will offer meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques. 1. The Interdisciplinary Team (IDT) identifies each resident's physical, emotional, or metal challenges and needs (e.g. wheelchair, ambulatory, visual or hearing impairment, happy or sad affect, evidence of dementia, etc.) during the resident assessment process. 2. Residents with special needs are discussed with the IDT during care planning. The Activity Department coordinates care planning with nursing and other members of the IDT to develop an effective approach for meeting special activity needs of residents. Review of the provider's revised 2/1/13 Activity Director job description revealed: The Activities Director provides for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being of each resident. 1. Provide an activities program on a daily basis including evenings and weekends. Provide a plan of activities appropriate to the needs of the residents that includes, but is not limited to: -Opportunity for resident involvement in planning and implementation of the activities program. -Assure that at least thirty (30) minutes of staff time is provided per resident per week for activities duties. -Prepare a monthly calendar of activities written in large print and posted in a prominent location that is visible to residents and visitors. -Assess resident needs and develop resident activities goals for the written care plan. -Encourage resident participation in activities and document outcomes. -Review goals and progress notes. 5. Promotes effective working relations and works effectively as part of a team to facilitate the (facility name) area ability to meet its goals and objectives. -Assist in training new staff, assures new employees are being well orientated, and provides re-training as needed.	2020-09-01
166	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	726	G	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, personnel file review, job description review, and policy review, the provider failed to ensure an orientation program had been completed for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Interview with the DON, infection control nurse (ICN)/staff development, and licensed social worker (LSW) on 3/6/18 at 2:30 p.m. revealed: The current census for the memory care unit (MCU) was nine. They could have up to thirteen residents in the MCU. The usual staffing pattern for the MCU consisted of: -Two staff on the day shift from 6:00 a.m. through 2:30 p.m. -One staff on the evening shift from 2:00 p.m. through 6:00 p.m. -One staff member on the night shift from 6:00 p.m. through 6:30 a.m. -They usually worked twelve hour shifts. -Someone from the Warren wing would go back to cover breaks for the MCU person. -One nurse covered the Warren wing and MCU. -They usually had an UAP for the MCU. 2. Review of licensed practical nurse (LPN) B's personnel file revealed: A hired date of 1/17/18. There was no documentation of a competency checklist in her file. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding her orientation revealed: She had started on 1/17/18. She worked the day shift from 6:00 a.m. through 6:30 p.m. She mostly worked on the Warren wing and the MCU. Her orientation had consisted of medication pass, documentation, and had not sat down side-by-side with the other nurse training her. If she had issues she could have called another nurse. She had received a little training on dementia. She had the orientation competency checklist in her backpack in her car. She had three days of orientation on the floor. She had been hired to work on Center but was on Warren. She thought she had been hired to replace LPN A to get her off the floor and into an office job. LPN A had been her mentor. She had learned about the residents on the MCU by herself. She had requested more orientation to the administrator and the director of nursing (DON). Further interview on 3/7/18 at 3:15 p.m. with LPN B regarding her orientation revealed: She had received three to four days of training with LPN [NAME] She had carried the orientation checklist with her, but no one had asked to see it or sign off items she had completed. She had: -Filled in on another wing for a nurse -Not been oriented to that wing. Who were they going to put with me, there weren't any nurses, two nurses had quit. On her third day or orientation she was by herself down Center wing and was instructed by LPN A to let her know if she needed anything. No one had told her when she needed to have the orientation checklist completed. No one had followed up on her to see if she had completed the orientation checklist. Review of LPN B's nurse competency checklist and medication administration observation checklist provided by LPN B revealed: There was no documentation on either sheets indicating it had not been completed. Interview on 3/7/18 at 2:27 p.m. with LPN/staff development J regarding new employee general orientation revealed: She had been employed three years ago. March (YEAR) she started in the position of staff development and infection control. General orientation consisted of: -The first day was spent going over mandatory topics. -They completed the general orientation checklist on the first day of orientation. -The competency checklist was done with whoever their mentor was. -New hires were given ten shifts. If they needed more or less shifts they were to let her know. -The competency checklist should have been completed by the end of the ten days. -As the staff development nurse she should have been following up with the new hires. LPN A had been LPN B's mentor. LPN A had: -Provided the education. -Had done most of LPN B's orientation. Interview on 3/13/18 at 10:46 a.m. with the DON regarding general orientation revealed: New employees were to complete the general orientation checklist by the end of their orientation. The time frame for the general orientation was around ten shifts depending on how comfortable the person felt. The mentors were to have signed off the general orientation checklist as tasks had been completed. Interview on 3/8/18 at 1:50 p.m. with the administrator confirmed there was no orientation checklist in LPN B's personnel file. 3. Review of CNA/UAP D's personnel file revealed: A hired date of 10/23/17. The general orientation checklist was dated 3/9/18. There was no documentation of a CNA competency checklist in her file. The medication technician competency checklist was dated 3/9/18. Interview on 3/8/18 at 9:45 a.m. with CNA/UAP D regarding her general orientation training revealed: She had transferred from another sister facility around (MONTH) 1, (YEAR). She did have general orientation consisting of going over different topics. She had been hired to work in the MCU. She had watched the Hand in Hand video. She had no other training on dementia. That had been her first exposure for working with residents with dementia. She did not remember getting a competency checklist when she had started employment. Interview on 3/13/18 at 10:15 a.m. with the administrator regarding CNA/UAP D's personnel file revealed: Her expectations would have been to complete the orientation checklist and competency checklists sooner. They should have been done by the time she was through with orientation. Interview on 3/13/18 at 1:39 p.m. with LPN A regarding orientation of new employees revealed: She had done orientation with new employees. She oriented them to computer use, electronic medical records, charting and documentation, phone numbers, and what to do in emergency situations. The new employees would be oriented to ten shifts. If the new employee: -Was comfortable with less shifts they would allow them to work independently. -Wanted more than ten shifts for orientation they would honor that also. 4. Review of the provider's (YEAR) Employee Handbook revealed: Training and Professional Development: -(Facility name) recognizes the importance of encouraging and supporting employees in professional development activities that are related to their employment. -(Facility name) is responsible for identifying, creating, and providing opportunities for professional development and training to enhance and build the capacity, skills excellence and professionalism of employees to enable them to contribute effectively creatively encouraging and supporting appropriate learning experiences. -Individual employees are responsible for assessing their job related skills and knowledge, for maintaining a high level of performance throughout their employment and for seeking approval for appropriate professional development and training opportunities in consultation with their supervisors. -Supervisors are responsible for working with their employees to identify needs and for creating a professional development and training plan that will benefit the unit as well as the individual. Review of the provider's (MONTH) 2013 LPN job description revealed: General description: -Are responsible for assessing, planning, implementing, and evaluating the care of a designated group of residents in a designated time frame. -Demonstrates knowledge of gerontology residents physical, social, emotional and psychological needs based upon the residents care needs. Essential functions: -Monitors and documents changes in health status through continuing assessment of the resident. -Implements the plan of care, using appropriate nursing action. -Transcribes and carries out physician's orders [REDACTED]. -Observes, records and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. -Directs and supervises non-licensed staff in resident care. -Works closely with nursing assistants. Assures the CNA has appropriate information to provide care to the residents. -Knows and is able to carry out approved emergency procedures. -Follows and enforces back safety precaution for lifting and moving residents and other items. Review of the provider's (MONTH) 2013 CNA job description revealed: General description: -Responsible to provide direct, hands-on care to residents to ensure residents attain or maintain the highest possible physical, mental and emotional well-being possible for each resident without declines in status unless the decline is documented as unavoidable. Review of the provider's undated Director of Staff Development job description revealed: [NAME] Staff Development/Education: -Assures that staff receive sufficient training and orientation to perform his/her duties. -Develops/coordinates/assists with instruction in general orientation. -Assures all staff complete required orientation topics before they begin work in their departments. -Assures all employees receive a comprehensive orientation that covers all required topics per facility policy, procedures, orientation checklists and law. -Assures that all employees training checklists and on-the-job orientation is completed within 30 days after starting work in their area. -Trains others to coach and mentor knowledge and skills. Review of the provider's (MONTH) 2013 DON job description revealed: Is responsible for the daily direct care services. Supervises the nursing department and makes sure (name of facility) is in compliance's with all nursing related rules and regulations. Observes, mentors, and trains new and current staff to facility's programs, policies and procedures and holds staff accountable for duties assigned. Review of the provider's (YEAR) Staff Development Program revealed: All personnel must participate in initial orientation and regularly scheduled in-service training classes. The primary purpose of the in-service training program is to provide our employees's with an in-depth review of our established operational policies and procedures, their positions, methods and procedures to follow in implementing assigned duties, and to provide up-to-date information that will assist in providing quality care. Refer to F600, F609, F610, F657, F658, F679, F744, F745, and F842.	2020-09-01
167	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	744	H	1	0	Z0T511	> Based on observation, interview, record review, policy review, and job description review, the provider failed to: Provide the necessary care and services for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment to reach his/her highest practicable level of physical, mental, and psychosocial well-being. Develop policies and procedures for all residents residing on the memory care unit (MCU). Develop a care plan with measurable goals and interventions to address the care and treatment for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who had cognitive impairment. Identify, document, and communicate specific targeted behaviors for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) residing on the MCU. Ensure staff had the skills and qualifications to assess residents' with behaviors for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: Surveyor: 1. Interview on 3/13/18 at 10:46 a.m. with the director of nursing (DON) and the administrator regarding policies and procedures revealed the provider had: A policy regarding admission criteria for the MCU. No policies and procedures specific for the care of the residents residing on the MCU. Surveyor: Review of the provider's (YEAR) Dementia - Clinical Protocol policy revealed: Assessment and Recognition: -1. The physician will help identify individuals who have been diagnosed as having dementia or otherwise irreversibly impaired cognition. -5. The staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. -6. The staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. -8. The staff and physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and considerations about healthcare treatment choices, including life-sustaining treatment. Treatment/Management: -1. For the individual with confirmed dementia, the staff and physician will identify a plan to maximize remaining function and quality of life. -2. The physician and staff will identify and address ethical issues and related treatment options. Monitoring and Follow-up:-1. The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. -2. The physician will help staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, etc. Refer to F600, F609, F610, F657, F658, F679, F726, and F745.	2020-09-01
168	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	745	F	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, interview, policy review, and job description review, the provider failed to identify and promote individualized approaches to care that meet the mental and psychosocial needs for two of two closed resident records(1 and 2)and three of three sampled residents (3, 4, and 5). Findings include: 1. Review of resident 2's medical record revealed: An admission date of [DATE]. [DIAGNOSES REDACTED]. The 9/8/17 admission Minimum Data Set (MDS) assessment indicated his Brief Interview for Mental Status (BIMS) score had been a four indicating severe cognitive impairment. Review of resident 2's behaviors documented by the certified nursing assistant (CNA) staff in the behavior tracking reports and by the nursing staff in the interdisciplinary progress notes (IPN) revealed: For (MONTH) (YEAR): -On 12/24/17 at 5:35 p.m. registered nurse (RN) O documented on resident 1's fall report that resident 2 was standing near her and said If you don't move I will back into you. CNA D reported to nurse that he did back into her causing her to lose her balance. --There were no behaviors documented in the behavior report and/or the IPN. -There was no facility and Department of Health (DOH)event report completed for this date. For (MONTH) (YEAR): -On 1/5/18 at 7:30 p.m. CNA L documented physical altercation with staff and resident, hitting or trying to hit them. The staff and resident names were not identified. -On 1/16/18 at 9:45 a.m. CNA D documented Resident threatened another resident, said several times that if this particular resident came near him again he would knock her out and throw her into the river. The resident was not identified. -On 1/19/18 at 7:00 p.m. CNA K documented Hit res (resident) in left breast. The resident was not identified. -On 1/20/18 at 1:43 p.m. CNA/unlicensed assistive personnel (UAP) [NAME] documented Resident is very aggressive to others. -On 1/21/18 at 3:38 p.m. CNA L documented resident went into room (resident 5) was yelling at resident to get the hell out of his bed. I'll hit/beat you if I have to. Resident was redirected to own room. Came right back to same spot. -On 1/21/18 at 4:15 p.m. CNA L documented Punching at another resident (3) and punching walls. -On 1/23/18 at 3:30 p.m. CNA K documented he cursed, screamed at others, and threatened others. At 4:00 p.m. he shoved others. -On 1/24/18 at 4:22 p.m. CNA D documented Resident punched other resident in the chest and arm might have bruising. The resident was not identified. -On 1/24/18 at 3:15 p.m. RN O completed a facility event report for a fall and a post event investigation form. --The 1/24/18 post event investigation form had documentation that RN O notified the supervisor at 4:30 p.m. of the resident-to-resident altercation. --The post event investigation form was signed by the administrator, director of nursing (DON), and MDS coordinator with no date and time of review along with a notation Aggressive resident. PCP (primary care physician) contacted in regards to behaviors. -- On 1/24/18 at 10:14 p.m. RN O documented a behaviors note in the IPN Resident to resident altercation, pushed resident (resident 1) causing her fall, with contusion to the back of her head, he was agitated with her repetitive echolalia. -On 1/25/18 at 7:06 a.m. LPN C documented a behaviors note in the IPN Pushed another resident and made her fall. She hit her head. Resident went to bed right after supper and stayed there all night. --There was not a facility and South Dakota Department of Health (SD DOH) event report completed for this date. -On 1/25/18 at 2:21 p.m. the DON documented a nursing note in the IPN PCP faxed in regards to resident having increased aggressive behaviors recently. The 1/25/18 fax revealed: --Resident has been having increased aggressive behaviors, most of which are directed towards other residents in our memory care unit. --Most recently (resident 2's name) pushed another resident onto the floor. --Other times he will do things to scare other residents, staff reports he frequently pushes, grabs at, and yanks other residents. --He has been seen attempting to trip a resident on a few different occasions. --He gets very upset, believing that his wife is having an affair and she and her boyfriend are taking everything. --Staff reports that (resident 2's name) frequently talks down about the people he is around, saying how disgusting and uneducated these people are and questions how staff can stand to be around them. --Staff reports seeing (resident 2's name wind up like he is getting ready to punch at someone and staff having to intervene. --We are wondering if it would be appropriate to refer (resident 2's name)to (provider's name)behavioral health for a medication adjustment. -On 1/28/18 at 4:00 p.m. CNA D documented hit resident 1 in the back and resident 3 in the chest. --There was no assessment note by the charge nurse documented in the IPN for that event. --There was no facility and DOH event report completed for that date. -On 1/31/18 at 8:00 a.m. CNA G documented Hit resident 1 in the left upper chest shoulder, witness by CNA K and housekeeper, and he was Mocking resident 1, making crying sound after hitting her. --There was no assessment note by the charge nurse documented in the IPN on that shift. --There was no facility and DOH event report completed for that date. For (MONTH) (YEAR): -On 2/1/18 at 5:30 p.m. CNA K documented Hit resident 5 and pushed to floor. Also documented at 5:30 p.m. he cursed, screamed at others, and threatened others. --On 2/1/18 at 5:50 p.m. LPN N completed a facility event report for a fall and a post event investigation form. --The post event investigation form was signed by the administrator, DON, and MDS coordinator with no date and time of review along with a notation PCP contacted about increased aggressive behaviors. medication changes. -On 2/1/18 at 6:52 p.m. LPN N documented a nursing note in the IPN Resident pushed down another resident in the residents room at 5:30 p.m. on 2/1/18. There was a lot of provocative language on (resident's name) part. -On 2/3/18 at 10:00 a.m. CNA D documented Told another resident that if she kept crying that he was going to punch her in the mouth. --There was no documentation in the IPN by the charge nurse for that event. -On 2/10/18 at 12:00 noon CNA M documented he hit others. --There was no documentation in the IPN by the charge nurse for that event. -On 2/17/18 at 11:00 a.m. CNA D documented he threatened others. --There was no documentation in the IPN by the charge nurse for that event. -On 2/21/18 at 10:00 a.m. CNA D documented Threatened to hit another resident in the mouth, several times because she was crying. --There was no documentation in the IPN by the charge nurse for that event. -On 2/21/18 at 12:15 p.m. CNA G documented he hit and scratched others. --There was no documentation in the IPN by the charge nurse for that event. --There was no facility and DOH event report completed for that date. -On 2/22/18 at 5:40 p.m. a resident-to-resident altercation with resident 1 and 2 occurred. --There was no documentation by CNA [NAME] of the physically abusive behavior on the facility tracking report. --LPN B completed a facility event report describing the event The resident could of been the one that punched, pushed, or hit another resident in the locked unit .He stood over the top of her mocking her, hollering out, and telling her to shut up. --LPN B completed a post-event investigation form that she notified the LSW who was the supervisor at 6:00 p.m. of the resident-to-resident altercation. --LPN B notified the PCP of the resident-to-resident altercation via fax. -The 2/22/18 post event investigation form had no documentation under the section for the nursing assessment for cause of event, interventions added to care plan to prevent further events, including education given to resident/staff. -The 2/22/18 post event investigation form was not reviewed and signed by the administrator, DON, and MDS coordinator. -On 2/22/18 at 8:30 p.m. CNA/UAP H documented resident 2 threatened others and reported his behavior to LPN C. --There was no assessment note by LPN C documented in the IPN for that event. Review of resident 2's 9/21/17 care plan revealed: A problem for wandering was stated with the following three goals: -001 - Resident will not wander out of facility. -002 - Will have no injuries related to wandering. -003 - Will not intrude on or endanger others, Some of his care plan interventions included: -0003 - Redirect when wandering. -0006 - Prompt activity attendance daily to keep resident occupied. -0007 - Observe resident's location to ensure safety. No revision and/or updates were made to his problem, goal, and interventions. No problem, goal, and interventions were documented for agitation on his care plan. No problem, goal, and interventions were documented for aggressive behavior on his care plan. Review of resident 2's 10/5/17 care plan revealed: A problem stated he required the use of a [MEDICAL CONDITION] medication. Some of his care plan interventions included: -0001 - MD (medical director) consult as needed. -0003 - Will monitor behavior. -0004 - Activities to evaluate for interests and skills/abilities. There were physician's orders [REDACTED]. -On 9/8/17 he was admitted on [MEDICATION NAME] 1 mg daily for mood stabilization. -On 10/16/17 he was discontinued on the [MEDICATION NAME]. -On 2/2/18 he was started on [MEDICATION NAME] 2.5 mg daily for aggression. -On 2/8/18 the [MEDICATION NAME] was ordered to be increased to 5 mg daily for aggression starting 2/9/18. No revisions and/or updates were made to his problem, goal, and interventions. Review of resident 2's undated pocket care plan for memory care staff revealed: He liked to swear. No interventions for agitation and/or aggressive behaviors were on his pocket care plan. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding the 2/22/18 resident-to-resident altercation revealed she: Worked the 6:00 a.m. to 6:30 p.m. shift. Was usually assigned to the[NAME]wing and the MCU. Went back to the MCU in the morning and again at 1:00 p.m. to administer medications. Did not know resident 2 and about his behaviors. Received directions from LPN C on how to complete the transfer and event form paperwork. Was informed by LPN C she had notified the LSW of the resident-to-resident altercation while he was still in the facility. Was informed by LPN C the LSW had instructed the charge nurse to fax: -Resident 1's PCP about the fall. -Resident 2's PCP about obtaining an order to transfer him to behavioral health. The LSW left the facility and did not assess the situation to ensure the safety of other residents. Interview on 3/7/18 at 10:14 a.m. with CNA H regarding resident 2's behavior revealed: She usually worked in the MCU two days per week. Resident 2 would sometimes get aggressive by being confrontational and raising his voice with residents. On 2/22/18 after the resident-to-resident altercation she had reported he was: -Very agitated and threatening other residents. -Going to defend himself if someone does something to him. -Talking about having to go to jail. She reported the above comments to LPN C and she was instructed to: -Document everything. -Leave resident 2 alone. She felt unsafe working in the MCU. Interview on 3/7/18 at 11:11 a.m. with the LSW regarding resident 2's care planning process revealed he: Was aware of his aggressive behaviors by reports heard at stand-up meetings. Was aware of his verbally aggressive behaviors toward his spouse. -She had reported to him he had accused her of drinking and/or having an affair. Pushed other residents in the MCU. Did not investigate those reports since the PCP was making medication changes. Did not address those behaviors on his care plan. Continued interview on 3/7/18 at 11:11 a.m. with the LSW regarding the 2/22/18 resident-to-resident altercation revealed he: Had clocked out and was walking through the facility when LPN C informed him I think (resident 2's name) may have pushed someone down, and they need to go to the hospital. Instructed LPN C To let the administrator or the director of nursing know. Denied recommendations to fax resident 2's PCP regarding a behavioral health referral. Stated It was more hearsay than reportable, so I left. When asked if he should of stayed to assess resident 2's behavioral problems he said, I did not actively think about how (resident 2's name) would act after the situation. Interview on 3/7/18 at 4:35 p.m. with LPN C regarding the 2/22/18 resident-to-resident altercation revealed she: Worked the 6:00 p.m. to 6:30 a.m. shift. Was scheduled as the charge nurse on East,[NAME] and MCU that date. Was aware of resident 2's aggressive behaviors. Was informed by LPN B of the fall event in the MCU. Reported to LSW on 2/22/18 at approximately 6:30 p.m. she had heard Two different stories resident 2 hit resident 1 or they suspected he hit her. Was instructed by the LSW To fax resident 2's doctor to get an order to send him to behavioral health. Was not instructed by the LSW to call the administrator and/or the director of nursing. The LSW left the facility and did not assess the situation to ensure the safety of other residents. Acknowledged on 2/22/18 at approximately 8:00 p.m. that CNA/UAP H reported to her resident 2 raised his fist at her and tried to hit her. Instructed CNA/UAP H to ignore resident 2 and she would go back to the MCU to check on him. -There was no communication to the PCP regarding resident 2's behaviors. -There was no documentation in the IPN regarding monitoring resident 2's behaviors. 2. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed: The (MONTH) (YEAR), 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-six of thirty days. Of those days the wandering behavior had: -Placed her at significant risk for twenty-six of thirty days. -Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. The (MONTH) (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed she did not display any behaviors. Review of the (MONTH) (YEAR), 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. Of those days the wandering behavior had: Placed her at significant risk for twenty-one of thirty-one days. Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. The (MONTH) (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed she did not displayed any behavior. Review of the (MONTH) 1 through (MONTH) 15, (YEAR) 6:00 a.m. through 6:30 p.m. entries revealed: She had wandered in hallways or other residents' rooms for nine of fifteen days. Of those days the wandering behavior: -Had placed her at significant risk for of thirty days. -Had significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. -There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. The (MONTH) 1 through 15, (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. -There was no further documentation in the medical record regarding what had prompted the behavior. Review of resident 1's 11/15/17 quarterly Minimum Data Set (MDS) assessment revealed: She had exhibited physically aggressive behavior symptoms toward others one-to-three days per week. She had not exhibited behavioral symptoms directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds in the seven day look-back period. She had overall presence of behavioral symptoms. Those symptoms put her at risk for physical illness or injury. Those symptoms put other residents at risk for physical injury. She wandered one-to-three days per week. That wandering significantly intruded on the privacy or activity of other residents. Wandering also placed the resident at significant risk of getting into a potentially dangerous place. Her behavior had worsened compared to the prior MDS assessment on 8/16/17. Review of resident 1's 11/16/17 through 2/14/18 Behavior Detailed Entry Reports revealed: For the (MONTH) 16 through (MONTH) 30, (YEAR) 6:00 a.m. through 6:30 p.m. entries revealed: She had wandered in hallways or other residents' rooms for seven of fifteen days. Of those days the wandering behavior had: -Placed her at significant risk for seven of fifteen days. -Significantly intruded on the privacy or activities of others for seven of fifteen days. The (MONTH) 15 through (MONTH) 30,2017 6:00 p.m. through 6:30 a.m. entries revealed she did not display any behavior. Review of the (MONTH) (YEAR) from 6:00 a.m. through 6:30 p.m. entries revealed: She had wandered in hallways or other residents' rooms for twenty-one of thirty-one days. Of those days the wandering behavior had: -Placed her at significant risk for seventeen of thirty-one days. -Significantly intruded on the privacy or activities of others for eighteen of thirty-one days. The (MONTH) (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed: -On 12/10/17 at 8:00 p.m. she had refused assistance with dressing. -On 12/11/17 at 10:00 p.m. she was Physically abusive. Hit staff. -There was no further documentation of behavior. Review of the (MONTH) (YEAR) 6:00 a.m. through 6:30 p.m. entries revealed: She had wandered in hallways or other residents' rooms for ten of thirty-one days. Of those days the wandering behavior had: -Placed her at significant risk for four of thirty-one days. -Significantly intruded on the privacy or activities of others for five of thirty-one days. The (MONTH) (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review of the (MONTH) 1 through 22, (YEAR), 6:00 a.m. through 6:30 p.m. entries revealed: She had wandered in hallways or other residents' rooms for six of twenty-two days. Of those days the wandering behavior had: -Placed her at significant risk for three of twenty-two days. -Significantly intruded on the privacy or activities of others for three of twenty-two days. The (MONTH) 1 through 22, (YEAR), 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review of her interdisciplinary progress notes (IPN) revealed: An 11/24/17 LSW quarterly MDS note indicated a history of wandering and physical behavior as well as wandering and exit seeking. A 12/8/17 note by LPN N indicated resident 1 had been grabbed on the arm by another resident (3) and was trying to shake her hand off. When the other resident would not let go she forcefully shoved the other resident. A 12/24/17 incident regarding a fall with a head injury. Review of the 12/24/17 fall report by registered nurse (RN) O revealed CNA D had observed resident 2 threaten to back into resident 1 if she did not move. RN O documented, Report is that he did back into her then backed into her causing her to lose her balance. Resident 1 fell hitting her head. A 1/15/18 note by LPN P at 5:29 p.m. indicated the resident was found on the floor with both legs in one pant leg. Another head injury was noted. A 1/24/18 note by RN O at 9:48 p.m. indicated the resident had a fall at 3:15 p.m. Caused by aggressive behavior of another resident. -Resident 1 received another head injury after being pushed by resident 2. The LSW was made aware of Verbal and physical aggression of the other resident. Two other resident-to-resident altercations occurred between residents 1 and 2 that were not documented in resident 1's medical record. Those events were recorded in resident 2's behavior tracking record: On 1/28/18 CNA D had documented resident 2 Hit resident 1 in the back and resident 3 in the chest. On 1/31/18 CNA G had documented resident 2 Hit resident 1 in the left upper chest shoulder, witness by (CNA K) and housekeeper and he was Mocking (resident 1), making crying sound after hitting her. Review of resident 1's 2/14/18 annual MDS assessment revealed: She displayed no physically or verbally aggressive behavior symptoms toward others in the seven day look-back period. No behavioral symptoms directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds had been exhibited in the seven day look-back period. She had no overall presence of behavioral symptoms. No behavioral symptoms had been acknowledged to have a negative impact on herself or others. She rejected care one to three days in the seven day look-back period. She wandered one to three days per week. That wandering significantly intruded on the privacy or activity of other residents. Wandering also placed the resident at significant risk of getting into a potentially dangerous place. Her behavior had remained the same compared to the prior MDS assessment on 11/15/17. Further review of resident 1's IPN and interview with LPN B revealed: On 2/21/18 at 6:05 p.m. LPN B documented, Patient (resident) was struck by another resident, in the chest she is fine no marks or bruising so far, made her nervous. -Interview on 3/8/18 at 1:00 p.m. with LPN B revealed she did not know who had struck resident 1, nor when the event had occurred. -Interview on 3/8/18 at 1:07 p.m. with CNA G revealed she had witnessed resident 2 punch resident 1 in the chest. CNAs G and D had placed her in a chair and called LPN B to come check her. -No reports had been completed at the time of the event On 2/22/18 at 10:53 a.m. the LSW documented a care conference was held with the LSW, RN clinical coordinator/MDS coordinator, dietary manager and resident 1's power of attorney (attended by phone). The LSW documented: -She was on a one-to-one list once weekly for activities. -She had lost thirteen pounds in six months. -The primary physician saw her on 2/13/18 and stated she was tolerating her medication well. -She was requiring more assistance with her activities of daily living. -She was unable to formulate words, and continued with echolalia. -There were no concerns noted during the conference. There was no documentation by the IDT members of the falls, head injuries, or numerous episodes of physical aggression and mocking toward resident 1 by resident 2. Review of resident 1's 1/16/17 wandering care plan revealed: She had wandered. Her goals were she: -Would not wander out of the facility. -Would not intrude on or endanger others. Interventions included: -To maintain a safe environment. -To prompt activity attendance daily to keep her occupied. -Staff were to observe her location and provide safety. A 1/16/18 Fall care plan stated she was at risk for falls. Her goal was for no falls. Interventions included: -She would receive supervision with transfers, locomotion, and walking. -Staff were to prompt her to ask for assistance. -Prompt her to attend activities that did not put her at risk for falls. -Safety training and education as needed. -Provided a safe environment. -Frequent observation. The above care plan had not addressed or been updated to address interventions regarding resident 1's: Falls with head injuries. Pacing as acknowledged by the primary physician. Episodes of physical behavior directed toward staff. The episode of physical aggressive behavior toward resident 3. Multiple episodes of verbal and physical aggression by resident 2 toward resident 1. Echolalia and disruptive sounds that reportedly placed her at risk of resident 2's aggression. Review of the undated pocket care plan utilized by the direct care staff on the MCU at the time resident 1 had resided there revealed: Fall risk. Independent with walking. Wander device on. Make sure she has on non-skid foot wear. There was no mention of the concerns below, or any interventions for her: -Aggressive episode with resident 3. -Wandering on the unit and frequent intrusions in other residents' rooms. -Echolalia and repeated verbal vocalizations, and the impact it might have on other residents. -Her frequent falls and head injuries as a result of physical aggression by another resident. Interview on 3/7/18 at 11:11 a.m. with the LSW revealed resident 1's nursing and pocket care plans should have: Addressed all areas of behavior concerns that had been exhibited. Provided interventions specific for those behaviors. Surveyor: Continued interview at the above time with the LSW regarding resident care planning process revealed he: Was responsible to develop problems/strengths, goals, and interventions for the following focuses: -Psychosocial. -Wandering. -Cognitive impairment. -Behaviors. Reviewed and revised residents' care plans quarterly after care conferences and/or as families requested. Reviewed the facility's care tracker program for residents' behaviors during the seven day assessment period to complete the quarterly MDS. Did not complete a ninety day look back of residents' behaviors and/or interventions implemented by the MCU staff on the care tracker program. Would spend some time in the MCU two days per week. Did not collaborate with the MCU staff prior to developing and/or revising interventions to meet the residents' needs. Was part of the interdisciplinary team (IDT) and attended the stand-up meeting held at 9:00 a.m. Monday through Friday. Was responsible for investigating and completing the elopements and the misappropriation of resident property reports to the Department of Health (DOH). Assisted the IDT with investigating and completing the suspicion/allegation of abuse or neglect and the falls with injury reports to the DOH. -Would review the camera videos on the suspicion/allegation of abuse or neglect reports to assess frequency of staff in residents' rooms. Did not assist with investigating and completing the resident-to-resident altercations reports to the DOH. Surveyor: Interview on 3/7/18 at 11:15 a.m. with the LSW regarding his job responsibilities on the MCU revealed he: Filled out the following MDS assessment sections for each resident when they were due: -Identification information. -Cognitive patterns. -Mood. -Behavior. -Resident participation in assessment and goal setting. -Care area assessment summaries when needed. -Assessment administration for billing purposes. Attended care conferences with families. Was responsible for care planning behaviors including wandering, resident cognition, and psychosocial concerns. If a resident had behaviors with pain or dementia the care plan would be combined with the interdisciplinary team. Developed the residents' care plans after reviewing the seven-day look back period as part of the MDS. Only reviewed the Behavior Detailed Entry Reports for the seven-day look back period. Did not review documentation in the medical record/IPN notes outside the seven-day look back period or other behavior records as part of developing the behavioral care plan. Was not involved with the development or updating of pocket care plans that were utilized by the direct-care staff. The MDS coordinator had developed and updated those. Surveyor: Interview on 3/8/18 at 2:38 p.m. with the administrator regarding the IDT's responsibility of assessing, documenting, and care planning individualized resident specific care needs revealed she: Would expect the LSW to be responsible for assessing and evaluating residents' behavioral symptoms. Was not aware the LSW was not communicating with staff prior to developing/revising a resident's care plan. Agreed the pocket care plan was an extension of the facility's large care plan. -Was not aware behavioral interventions were not on the pocket care plan. Interview on 3/13/18 at 11:34 a.m. with the LSW revealed: He agreed the memory care residents' care plans and pocket care plans were not individualized to meet their mental and psychosocial needs. When he looked back and reviewed the reportable events there was a pattern with residents 1 and 2. As the social worker and manager he should have been more accountable for the 2/22/18 resident-to-resident altercation. He agreed they should have been more proactive, and it was unsafe to have resident 2 remain in the facility. Review of the provider's 8/17/17 Care Plans - Comprehensive policy and procedures revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: -a. Incorporate identified problem areas; -b. Incorporate risk factors associated with identified problems; -d. Reflect the resident's expressed wishes regarding care and treatment goals; -g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: -a. When there has been a significant change in the resident's condition/ -b. When the desired outcome is not met; -d. At least quarterly. Review of the provider's 6/1/16 Care Planning - Interdisciplinary Team policy and procedures revealed: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: -a. The resident's Attending Physician; -b. The Registered Nurse who has responsibility for the resident; -d. The Social Services Worker responsible for the resident; -e. The Activity Director/Coordinator; -h. The Director of Nursing (as applicable); -i. The Charge Nurse responsible for resident care; -j. Nursing Assistants responsible for the resident's care; Review of the provider's 4/12/17 Director of Social Services/Social Worker job description revealed: *Provides care to assigned residents in a caring, safe, and efficient manner; and is responsibl	2020-09-01
169	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	842	E	1	0	Z0T511	> Based on record review, interview, and policy review, the provider failed to ensure accurate documentation in the medical record for two of two resident closed records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: Surveyor: 1. Interview on 3/13/18 at 10:46 a.m. with the director of nursing regarding charting and documentation revealed she: Stated the certified nursing assistants (CNA) were documenting resident behaviors on the trend tracker. Was not sure if the CNAs had been reporting the behaviors to the charge nurse for assessment. Agreed the facility event reports were incomplete with: -Dates. -Signatures. -Pertinent information. Confirmed other facility event reports had not been completed at the time of the incidents. Confirmed interdisciplinary progress note documentation had not been complete. Surveyor: Review of the provider's (MONTH) (YEAR) Charting and Documentation policy revealed: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 3. All incidents, accidents, or changes in the resident's condition must be recorded. 7. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: -a. The date and time the procedure/treatment was provided; -c. The assessment data and/or any unusual findings obtained during the procedure/treatment; -f. Notification of family, physician or other staff, if indicated; -g. The signature and title of the individual documenting. Refer to F600, F609, F610, F657, F658, F679, F726, F744, and F745.	2020-09-01
170	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	226	D	0	1	80K911	Based on record review, interview, and policy review, the provider failed to ensure two of six sampled residents (2 and 16) with incidents requiring an investigation had them completed and documented thoroughly. Findings include: 1. Review of a 5/16/17 Grievance/Event Report for resident 16 revealed: Report of Event: (First name of family member) was concerned about bruising on (resident name) forearms and elbows. Witness to Event: Left blank. Completed by: Signed by licensed social worker (LSW). Date of event: 5/16/17; Time: Left blank. Investigation: Discussed with CNAs (certified nursing assistant), restorative staff and nurses. Determined that there could be 3 sources 1) arm rest of w/c (wheelchair), 2. happening during transfers with lift or 3. While using parallel bars in therapy. Follow Up Actions of Resolve: 1. Sheepskin was ordered to pad w/c arms. 2) & 3) Staff was instructed to be mindful of position of res (resident) arms during transfers and while using parallel bars. The investigation did not include: -Names of staff they interviewed. -How they reached the conclusion for the follow-up action. -What occurred during transfers with the lift or using the parallel bars that might have caused the bruising. -Was there something the staff were or were not doing that warranted them being mindful when using the lift or parallel bars. Interview on 8/2/17 at 1:45 p.m. with the director of nursing regarding resident 16's above bruise investigation revealed: They did not have additional documentation of the investigation into that event. She confirmed there was missing information in that investigation. Review of the provider's Abuse Neglect and Exploitation-Clinical Protocol policy revealed: 1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source, the Nurse Supervisor on duty must complete and (an) event form and record such information into the resident's clinical record. 3. Documentation shall include information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms. Any descriptions in the medical record shall be objective and sufficiently detailed (size and location of bruises) and should not speculate about causes. 5: With the help of the staff and management, the investigator will compile a list of all personel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the past 48 hours. 6. The investigation will follow the protocols set forth in our facility's established abuse, neglect, and exploitation investigation guidelines. 2. Review of resident 2's medical record revealed a 10/18/16 admitted . Review of resident 2's 4/13/17 Brief Interview for Mental Status score (BIMS) revealed a score of fifteen that indicated intact mental functioning. Review of resident 2's 4/11/17 Grievance/Event report form revealed: Resident came to licensed social worker's (LSW) office to notify he was missing $140.00. He states on 3/25/17 his ex-wife brought him $160.00 which he added to $40.00 he had. He states he used that money on 4/3/17 to order a pizza from Pizza Hut which he used $30.00, leaving him $170.00. Today he looked in his wallet and noticed there was only $30.00 remaining. He states the last time he knew it was all there was on 4/3/17 at 5:00 p.m. when he ordered the pizza. He thinks the money could have only gone missing while he was at meals as he is usually in his room and states he takes his wallet with him during medical appointments. LSW called ex-wife and she confirmed she brought him $160.00 but does not know what day specifically she brought it in. On 4/14/17 staff development nurse interviewed staff working on current shift. Staff was questioned about how often he orders pizza and if they knew about any missing money. Both staff state the frequency of him ordering pizza varies from week to week. They state he sometimes orders pizza multiple times a week and sometimes it is one time per week. Staff reports the only thing they knew about the missing money was when the resident spoke with them about it on 4/14/17. On 4/14/17 the LSW spoke with five residents on the east wing. Each resident stated they do not have any missing money. They also stated they don't have items that go missing often. Each resident was asked if they think theft is a problem at Southridge to which they responded no. In conclusion the allegation of misappropriation of resident funds has been unsubstantiated. Southridge can not find any fault in staff, other residents, or the staff. Interview on 8/1/17 at 5:00 p.m. with resident 2 revealed he: Confirmed he was missing about $200.00 a few months ago. Had reported it to the LSW. Thought the facility had looked into it thoroughly. Thought the staff member that was recently terminated for stealing was the one who had taken it. Had never been compensated for any of the missing money. Interview on 8/2/17 at 1:30 p.m. with the LSW and director of nursing regarding resident 2 revealed: The resident was alert and oriented. At times he was forgetful when he had a urinary tract infection. During the time the above money was missing he was not forgetful. They had not interviewed any of the staff who had cared for him from 4/3/17 when he had last seen the money until 4/11/17 when it was missing. The only two staff they had spoken to were on duty 4/14/17. They had not reviewed the camera footage like they had for some of the recent episodes of missing money from residents. The only thing the camera footage would have shown them is who had gone into his room during that time frame and not what they were actually doing in his room. They had not personally asked the resident how many times he ordered pizza, nor had they spoken to Pizza Hut to confirm how many times he had ordered pizza. *They agreed they likely could have investigated his missing money more thoroughly.	2020-09-01
171	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	281	D	1	0	80K911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to ensure professional standards were followed for the documentation of one of one sampled resident (14) who had a change in condition. Findings include: 1. Review of resident 14's medical record revealed: A [DATE] admitted . Diagnosis: [REDACTED]. He had an indwelling Foley catheter. He had been on hospice services at the facility. The hospice services had been discontinued on [DATE] related to stabilization in his medical condition. He was hospitalized in the intensive care unit on [DATE] after a change in condition. His catheter was changed in the emergency room due to being plugged. He had a large amount of bloody urine output after the new catheter was inserted. He was given three intravenous antibiotics in the emergency roiagnom on [DATE] for the [DIAGNOSES REDACTED]. He was transferred to a hospice facility after the hospitalization and expired on [DATE]. Review of resident 14's [DATE] physician's orders [REDACTED].>Change number 16 french Foley with 10 cubic centimeters (cc) balloon the first of the month and as needed (PRN). [DIAGNOSES REDACTED]. Review of resident 14's (MONTH) (YEAR) and (MONTH) (YEAR) treatment records revealed there was: Documentation his Foley catheter was changed on [DATE] and on [DATE] for the monthly changes. Documentation his Foley catheter was changed on [DATE] as it had been leaking with no urine output in the drainage bag. No documentation of any difficulties with the above Foley catheter changes. Review of resident 14's [DATE] nursing progress notes by registered nurse (RN) D revealed: 12:41 p.m.; Contact made with daughter. Resident leans to right when in wheelchair. Does not have equal strength in both hands. Does respond to staff. Blood pressure (B/P) ,[DATE], pulse 100 and irregular. Respirations 20. Oxygen applied at 2 liters per nasal cannuala and saturation 90 percent (%). Daughter states will be out shortly to see resident. Resident was up for lunch but laid back down in bed due to condition change. Noon meds held due to condition change. Did not eat lunch. 12:46 p.m.; Doctor's clinic contacted and updated. 12:53 p.m.; Daughter here and requests resident be evaluated by physician. Contact made with doctor's clinic and order to transfer by ambulance (hospital name). 1:32 p.m.; Ambulance summoned at this time. Family at bedside. 1:39 p.m.; Hospital emergency room contacted and report given to emergency room nurse. 1:53 p.m.; Resident left facility via ambulance enroute to hospital. Family present. Interview on [DATE] at 1:40 p.m. with the director of nursing regarding resident 14 revealed she: Was uncertain why the ambulance had not been called for thirty-nine minutes after the order had been received from the doctor. Thought maybe they had been waiting for the daughter to arrive at the facility. Had been on vacation on [DATE] and was not aware of the events surrounding the incident. Was not sure why there had been no nursing documentation on his condition from 12:46 p.m. until 1:53 p.m. when he had been transferred to the hospital. Stated she had spoken to RN D about the above when she had returned from vacation. RN D was not available today. They used the South Dakota Board of Nursing as their reference for professional standards. Review of the provider's [DATE] Charting and Documentation policy revealed: All services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. *All incidents, accidents, or changes in the resident's condition must be recorded.	2020-09-01
172	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	309	D	0	1	80K911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure a complete assessment of possible causing factors of falls for one of one sampled resident (3) with multiple falls. Findings include: 1. Random observations from 7/31/17 at 3:00 p.m. through 8/2/17 at 11:00 a.m. of resident 3 revealed she: Resided in the secured memory care unit (MCU). Could verbally communicate her needs. Was confused but oriented to herself, the situation; her long and short term memory were impaired. Used a wheelchair for mobility around the unit. Was able to tell the staff when she needed to go to the bathroom. Frequently laid down in her bed between meals. -Her bed was in a low position, and the door to her room was closed. Interview on 7/31/17 at 4:30 p.m. with certified nursing assistant (CNA) C regarding resident 3 revealed: She was able to tell the staff when she needed to go to the bathroo,. She repeatedly requested to go to the bathroom. -Sometimes they would take her to the bathroom, and she would immediately ask to go again. --She would spend a lot of time in the bathroom feeling the need to go. Review of resident 3's 7/30/17 physician's orders [REDACTED]. That order had been started on 4/10/16. Interview of CNA B on 8/1/17 at 9:00 a.m. revealed: She had started working in the facility on 7/24/17. It was her first day in the MCU. She did not recall specific training for working with residents with dementia but had previously worked in a MCU in another facility. Observation on 8/1/17 at 9:55 a.m. of CNA B regarding resident 3 revealed: The resident had been sitting in the day room and stated she needed to go to the bathroom. The resident wheeled herself to her room with CNA B going with her. CNA B pushed her wheelchair up to the bathroom door of the resident's room and because it was a large wheelchair it would not fit in the bathroom. The resident said she could stand up by grabbing the sink to then sit on the toilet. The CNA then came out of the bathroom, locked the wheelchair brakes, and stood behind the wheelchair while the resident stood up. The resident sat briefly on the toilet and said she was done. -She then stood back up and self-transferred to her wheelchair with standby observation by the CN[NAME] -She immediately said I have to go to the bathroom. and was transferred again to the toilet. At that time CNA C entered the room and asked if the CNA needed any help. -CNA B said she was doing fine. Interview of CNA B at that time revealed: She used a pocket care plan to know how to care for the residents and handed the surveyor the documented care plan. Review of resident 3's pocket care plan at that time revealed: -Assist of 2, w/c (wheelchair), NWB (no weight bearing) to l (left) arm, immobilizer on at all times, keep arm in front of body. Hi/lo bed, pillow under mattress to aid with positioning. Assist of 1 with cares. Fall risk. Tab alarm/voice command for bed/chair. It was dated 5/19/17. -The CNA was surprised the pocket care plan said that. Interview on 8/1/17 at 10:00 a.m. of CNA C revealed: The above reviewed pocket care plan had been an old one. She went to get an updated one where they were kept, but they were all dated 5/19/17. Resident 3 required only stand by assist with transfers and no longer used the immobilizer on her arm. -That had been discontinued about two months ago. She no longer had a TABs monitor. She was unsure why the pocket care plans available to them were so old. Review of resident 3's Fall reports from 11/8/16 through 7/17/17 revealed: 12/31/16 Description of Fall: She was found on the floor next to her bed. -Nursing assessment stated: Resident most likely thought she needed to use the toilet. Resident reminded to use call light. Staff asked to check on resident more often. --They had not assessed when the last time the resident had been taken to the bathroom. 1/14/17 Description of Fall: Found w/back (with bath) leaning on toilet w/legs stretched in front in bathroom door. Attempting to transfer off toilet. -They had not documented if staff had taken her to the toilet or if she took herself to the bathroom. 2/18/17 Description of Fall: Resident found sitting next to her door behind her wheelchair. She was incontinent of stool. -Nursing assessment stated: Educate staff on checking tab alarm connections during shift. 3/1/17 Description of Fall: Found sitting on floor in room. Had been in w/c. Alarm was sounding. States hit her head pointing to posterior scalp. -What was resident attempting to do at time of fall? Not sure. Maybe trying to go to restroom. --They had not assessed when the last time the resident had been taken to the bathroom. 3/12/17 Description of Fall: Staff alerted by chair alarm, found sitting on floor in center of her room. Unable to give account as to what she was doing. -Not able to determine what the resident was attempting to do. --Staff were to continue frequent monitoring. 4/23/17 Description of Fall: Resident found sitting on floor by bed--states slid off the bed when getting up to bathroom. -They had not assessed when the last time the resident had been taken to the bathroom. 4/30/17 Description of Fall: Was summoned to MCU by another nurse-1st responded staff person heard resident yelling help I've falling (as written); was noted right wheel landing on floor and buttock. -Staff were reminded to keep bed in lowest position. 6/10/17 Description of Fall: Resident states was trying to get to bathroom. Attempted to get up and slid out of w/c (wheelchair). --They had not assessed when the last time the resident had been taken to the bathroom. 6/27/17 Description of Fall: Unwitnessed found w/back (with bath) resting on bed. -What was resident attempting to do? Probably go to BR (bathroom) it was time for her to get up. --They had not assessed when the last time the resident had been taken to the bathroom. Review of resident 3's physician's progress notes revealed: 3/30/16: Urology Consult: pt (patient) evaluated for polyuria. She is requesting to go to the bathroom [ROOM NUMBER]-20 times in an 8 hr (hour) shift. 7/20/16: Urology Consult: Pt has no complaints from urology standpoint. Feels she voids with reasonable frequency during the day. Denies nocturia or incontinence. No change. -There were no further urology consults. 9/27/16 Primary Care physician (PCP): Chronic Problem list: Polyuria unchanged. No input by urology. (arrow up for increased) falls 2 (secondary) to arrow up (increased) bathroom trips. No change. 11/27/16: Polyuria/Urinary incont (incontinence). Polyuria continues impressively. No change. 12/13/16: Had fall with staples. In restorative cares to minimize falls. Part of problem is polyuria (has seen urology). No change. 1/8/17: Fall with fractures (12/28/16) of proximal humerus (left). Hx (history) of multiple falls this year. Past medical history: polyuria urinary incontinence. 1/21/17: Urinary incontinence. (arrow up) polyuria and (arrow up) falls. Will refer to neurology. -There was no referral to urology. 5/9/17: Urinary frq (frequency) and incontinence. Is out to neurology thinking normal pressure [DIAGNOSES REDACTED] with hx (history) falls, (increased) urination, new incontinence and (increased) confusion but neurologist failed to agree. A further interview on 8/2/17 at 8:00 a.m. with CNA C regarding resident 3 revealed: She was toileted every two hours. Sometimes when she was offered to go to the bathroom she would say she did not have to go. Sometimes she felt she had to go even after she had just gone to the bathroom. -She felt an urgency, but then did not have to. She thought she emptied her bladder when she went go to the bathroom. She was incontinent infrequently. Maybe one time a week and it was usually when she was sleeping. With hesitancy she said she thought all her requests to go to the bathroom might have been a behavior. She did not know. When the resident stated I have to go now then she really needed to urinate. But when she said over and over I have to go she usually did not. Interview on 8/2/17 at 9:00 a.m. with registered nurse D regarding resident 3 revealed: She concurred the resident needed to go to the bathroom often, and that had contributed to her falling. A neurological consult had been completed. She would have thought they would have reviewed her medications related to her urinary disorder, but she could not find documentation that had occurred for over a year. She agreed that with her increased urination a urinalysis (UA) would have been appropriate. -She did not think the medical director wanted so many UAs completed, because they had been done too often. Interview on 8/2/17 at 9:10 a.m. with restorative aide [NAME] regarding resident 3 revealed: They worked with her about five days per week. Sometimes she would get mad and swear at them, but usually she was cooperative. She had to go to the bathroom all the time. -There were times when they took her to the bathroom, and she would immediately need to go again. Interview on 8/2/17 at 11:30 a.m. with the physical therapist regarding resident 3 revealed: The physical therapist had worked with her for a period of time on ambulation. She continued to receive restorative nursing four to six times a week. She concurred that when they had worked with her she frequently needed to go to the bathroom. Interview on 8/2/17 at 1:30 p.m. with the director of nursing regarding resident 3 revealed: She confirmed the resident had multiple falls. She confirmed many of her falls were attributed to her urgency to go to the bathroom. Their investigations had not assessed when the resident had last been taken to the bathroom. She did not know why the door to her room was always closed, because she never used to ask for that. The resident had not had a urology consult for a year. -She agreed that would have been appropriate. However the resident was unable to go to an appointment alone, and she had no family to go with her. --It was very difficult to provide staff to accompany a resident to an appointment. She confirmed they had frequent communication with her physician, because she had so many falls. -She thought the physician might have become more complacent, because she had been doing that since she had been admitted . Review of the provider's (MONTH) (YEAR) Fall Risk Assessment policy revealed: The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls. The nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff, Attending Physician, and Consultant Pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or [MEDICAL CONDITION]. The staff, with the support of the Attending Physician will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence and cognition. The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.	2020-09-01
173	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	441	E	0	1	80K911	Based on observation, interview, manufacturer's instructions review, and policy review, the provider failed to ensure appropriate disinfection of residents' rooms by one of two (A) observed housekeepers. Findings include: 1. Observation and interview on 8/1/17 at 8:50 a.m. of housekeeper A cleaning a resident's room in the center hallway revealed she: Had worked there for two years as a housekeeper. Was one of two housekeepers working that day and would clean half of all of the residents' rooms. Performed hand hygiene and gloved. Emptied the garbage cans and dusted the room. Sprayed the toilet and bathroom surfaces with 3M Non-Acid disinfectant and cleaned the toilet bowl. Sprayed Clorox Fuzion onto a dry cloth, then added some Provon hand wash from the wall dispenser, and proceeded to wipe down the sink and countertop with that. Went back into the bathroom to wipe off the toilet and surfaces with a clean cloth. Five minutes had passed since spraying on the disinfectant. Finished cleaning the room. Stated she would always clean a room that way. Review of the manufacturer's instructions for 3M Non-Acid disinfectant revealed it took ten minutes to adequately disinfect surfaces. Review of the provider's undated procedure for Routine Room Cleaning revealed: Cleaning solution. (Follow directions on label.) No mention of what product was to be used nor the time it needed to be left on to adequately disinfect surfaces. Interview on 8/2/17 at 9:30 a.m. with the director of maintenance and housekeeping regarding housekeeper A's cleaning of residents' rooms revealed he: Agreed the 3M Non-Acid disinfectant took ten minutes on surfaces before being wiped off to adequately disinfect. Was unsure why she used the Clorox and Provon products together to clean the sink. Was unaware in the above policy there was no mention of the product used nor the time it needed to be left on surfaces to disinfect them. Interview on 8/2/17 at 11:40 a.m. with the director of nursing and the infection control nurse regarding disinfection of residents' rooms revealed: They had been unaware housekeeper A was cleaning residents' rooms as described above. They agreed that had not been adequate disinfection.	2020-09-01
174	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-08-08	610	E	1	0	25711	> Based on observation, interview, record review, and policy review, the provider failed to ensure three of three sampled residents (1, 3, and 4) had a thorough investigation completed for the following incidents for a resident fall with an injury, staff-to-resident abuse allegation, and a resident-to-resident abuse allegation. Findings include: 1. Interview on 8/8/19 at 9:15 a.m. with certified nursing assistant (CNA) C regarding resident 3 revealed she: Had just returned from vacation. Was not aware of the current fifteen minute checks related to a resident-to-resident incident that had occurred on 8/6/19 at 1:30 p.m. between resident 3 and another resident. Was unsure if the pocket care plan indicated the fifteen minute checks. Had not completed any fifteen minute checks today. Review of resident 3's 8/6/19 through 8/8/19, 15 Minute Check documentation sheet on 8/8/19 at 9:20 a.m. revealed: There were multiple areas on the document that were not completed. On 8/7/19 there was no documentation from 3:00 p.m. through 9:45 p.m. On 8/8/19 there was no documentation from 6:45 a.m. through 9:30 a.m. Observation on 8/8/19 from 9:35 a.m. through 10:00 a.m. of resident 3 revealed: The resident was sitting in his wheelchair in front of the television in the dining room. He was slumped over sleeping. Writer introduced herself with no response from the resident. He was unable to verbalize any response to questions asked. There was an unidentified staff person that came into the dining room to check on the resident at 10:00 a.m. Review of resident 3's 8/8/19, 15 Minute Check documentation sheet on 8/8/19 at 10:05 a.m. revealed the previous blank areas identified above were now completed and filled in from 6:45 a.m. through 10:45 a.m. Review of resident 3's current pocket care plan revealed there was no documentation related to his fifteen minute check interventions. Those interventions had been put in place on 8/6/19 after the resident-to-resident incident to ensure direct care staff were aware of the fifteen minute checks that had been put in place by licensed social worker (LSW) E. 2. Review of resident 4's staff to-resident abuse allegation investigation on 7/17/19 completed by LSW [NAME] revealed: There was documentation on the report to the South Dakota Department of Health there had been ten random residents interviewed in regards to the staff person involved. Review of the investigation conducted by LSW [NAME] revealed the investigations were incomplete and not thorough regarding the interviews conducted with the ten random residents. There had been no interviews documented with those residents. The only documentation was the residents names and a zero handwritten with a line through the zero. 3. Interview on 8/8/19 at 10:40 a.m. with the administrator regarding the above concerns revealed she: Was aware of documentation issues since (MONTH) 2019. Had completed audits regarding fall documentation, change in condition, and new admission charting. Would audit and then delegate to another staff member to complete the follow-up with the concerns identified. Interview on 8/8/19 at 11:45 a.m. with LSW B regarding investigations for allegations or incidents involving abuse and neglect, resident-to-resident altercations, staff-to-resident altercations, and falls revealed: She had begun her employment in (MONTH) (YEAR). She mostly worked in the rehabilitation unit but has been assigned to some long term care residents. She had been assigned to complete a few investigations by either the director of nursing service (DON) or the administrator. She was not aware of the provider's Abuse, Neglect, and Exploitation-Clinical Protocol policy and procedure. Interview on 8/8/19 at 11:30 a.m. with DON A regarding identified issues with documentation and thorough investigations revealed: She had been in her current position for a year. She was unaware of the provider's Abuse, Neglect, and Exploitation-Clinical Protocol. Discussion related to a thorough investigation regarding abuse and neglect investigations and all incidents. There was a discussion regarding: -The lack of documentation related to residents 3 and 4 interventions. -The filled in documentation related to resident 3's fifteen minute checks after the survey had begun, and the documented had been copied. 4. Review of resident 1's 7/16/19, 1600 (4:00 p.m.) Event Report and Post Event Investigation revealed: He had a bruise to the right inner thigh not of unknown origin and/or unknown. Licensed practical nurse (LPN) F had completed the report indicating it was a possible latent bruise that had surfaced after a fall that occurred on 7/9/19. -She speculated that, because the bruise was already yellow/green color. -She also indicated wheelchair pedals might have been a contributing factor for the bruise. The administrator, director of nurses, and resident care coordinator had signed the report as well as LPN F. Review of resident 1's interdisciplinary notes revealed: On 7/9/19 at 4:20 p.m. LPN F had documented the resident was on the floor. -He had been bending over and fallen forward onto his knees then onto his left side. -He had a skin tear to his left elbow that was assessed, cleansed, and dressed. -He denied pain and had no other injuries. On 7/10/19 at 11:51 a.m. LPN F documented her assessment and indicted, No latent injuries noted from fall. On 7/16/19 at 16:26 p.m. LPN F documented that resident was, Noted to have large bruise to (R) inner thigh. - Resident unaware of how/when this area occurred. There were no other notes in the intervening time between the fall and the discovery of an already yellow/green color bruise as to what might have been the cause. Review of resident 1's Non-Pressure Skin Condition Report revealed: On 6/28/19 he had an initial assessment completed by registered nurse (RN) [NAME] -There were six areas of concern documented about his abdomen, left knee, left lower leg, left great toe, and his right foot and ankle. On 7/5/19 there was no assessment done. On 7/12/19 LPN D completed an assessment reviewing the progress of the previously identified concerns; there was nothing about any new bruising to the right inner thigh. On 7/16/19 LPN F documented as an initial finding the yellow/green bruising to his right inner thigh. On 7/19/19 LPN F's documentation indicated fading green/yellow large bruise. Interview on 8/8/19 at 10:50 a.m. with LPN F about resident 1's fall and later bruise revealed: She agreed she had assessed him on the day of the fall on 7/9/19. - Had recognized all injuries at the time of the 7/9/19 fall were on the left side. -Had not included any speculation about injury resulting from wheelchair pedals. She agreed she had assessed him on 7/10/19 with no latent injuries noted from fall. On 7/16/19 she was notified by other staff, and she assessed the bruise to his right inner thigh. -Event Report indicates .not of unknown origin. -Post Event Investigation indicates unknown - had fall previously earlier in week. -She initiated the skin report for the right thigh. -She determined the wheelchair pedals might have contributed to the later bruise on the right thigh. Interview on 8/8/19 at 1:15 p.m. with LPN D about resident 1's skin condition report revealed: She agreed she had completed his skin assessment on 7/12/19, three days following his fall. She found the initial skin condition report completed on 6/28/19 by RN G to be overwhelming and difficult to follow. -There were too many areas identified, so it was hard to sort it out. -She did not recall any bruising to his right inner thigh, but if she had identified any new concern she would have documented the finding on another skin condition report. -She was not sure what the policy stated or if there was a policy related to completion of the skin assessments. She believed it would be easier to complete a more thorough skin assessment on the bath day rather than the day assigned by the room their in. Review of the provider's (MONTH) 2019 revised Abuse, Neglect, and Exploitation-Clinical Protocol revealed: The individual conducting the investigation would at a minimum complete the following: -Interview the person(s) reporting the incident. -Interview any witnesses to the incident. -Interview the resident (as medically appropriate). -Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident. -Interview the resident's roommate, family members, and visitors. -Interview other residents to whom the accused employee provided care of services. -Review all events leading up to the alleged incident. -Witness reports would be obtained in writing. Witnesses would be required to sign and date such reports. -An investigation of all unexplained injuries including bruises, abrasions, and injuries of unknown cause would be conducted by the director of nursing services, and/or other individuals appointed by the administrator to ensure the safety of the residents had not been jeopardized. -The nurse supervisor on duty must complete an event form and record such information in to the resident's clinical record. -Documentation should include information relevant and conditions that could cause or predispose someone to similar signs and symptoms. -Any descriptions in the medical records should be objective and sufficiently detailed. -The investigator would compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who had contact with the resident during the past forty-eight hours. -Signs of actual physical abuse included welts or bruises and abrasions.	2020-09-01
175	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-08-08	842	E	1	0	25711	> Based on observation, interview, record review, and policy review, the provider failed to ensure three of six sampled residents (1, 3, and 4) had thorough documentation of investigations related to staff-to-resident abuse, resident-to-resident abuse, and a fall with an injury that produced a latent bruise. Findings include: 1. Refer to F610, findings 1, 2, 3, and 4. Review of the provider's undated Charting and Documentation policy revealed: All services provided to the resident or any changes in the resident's medical or mental condition should have been documented in the resident's medical record. All incidents, accidents, or changes in the resident's condition should have been recorded. All forms (event, fall, and/or transfer) should have been filled out in its entirety. There was no clear direction in the policy and procedure for complete and thorough investigation documentation.	2020-09-01
176	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-08-29	565	E	0	1	81NC11	Based on record review and interview, the provider failed to follow-up on resident council concerns regarding baths not being done with resolution of that issue. Findings include: 1. Confidential interview on 8/28/18 at 1:00 p.m. with a group of residents revealed: Baths had not always gotten done on the days they were scheduled. One resident stated she was on the schedule for a bath yesterday but had not gotten it. -She had gotten one today. Sometimes the bath aides got pulled to work on the floor and would not have time to give baths that day. If staff called in sick they would not get baths that day. The hallway with the most concerns was the east hall. Review of the resident council minutes from 4/18/18 through 7/23/18 revealed: On 4/23/18 and 7/23/18 the residents had concerns about not getting baths. There had been no resolution or follow-up regarding baths not being done documented in (MONTH) (YEAR). -The follow-up in (MONTH) (YEAR) had been No lingering concerns. There had been no documentation of investigations into the concerns regarding baths not being done for (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR). Interview on 8/29/18 at 10:54 a.m. with the activity director revealed: She attended the resident council meetings. She typed up the minutes for those meetings. The follow-up with residents on if the issue had improved had not been documented. She had not known she was supposed to document resolutions of concerns in the resident council minutes. Interview on 8/29/18 at 11:11 a.m. with the administrator revealed: They had completed response forms for the above mentioned concerns that came out of the resident council meetings that had stated they were hiring staff. She was not aware the activity director had not been providing resolution to the resident council. *She agreed they had not investigated the issue of baths not getting done when they had been brought up in the meetings.	2020-09-01
177	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-08-29	684	E	0	1	81NC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to ensure one of three sampled residents (53) with diabetes received proper care and nutrition to avoid [MEDICAL CONDITION]. Findings include: 1. Review of resident 53's complete medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. He had a Brief Interview of Mental Status score of four. Indicating his cognition was severely impaired. He was grieving the loss of his wife. -She had passed away in (MONTH) (YEAR). He received the following medications for diabetes: -[MEDICATION NAME] 20 milligrams (mg) twice a day. --It was decreased to 10 mg twice a day on 8/27/18. -[MEDICATION NAME] 1000 mg twice a day. He received the above medications in the a.m. and at supper/dinner time. He had his blood sugar checked four times a day at: 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. Parameters to call the physician if the blood sugar was greater than 400 or less than 70. Review of resident 53's 7/28/18 care plan revealed: He had a potential for hyperglycemic or hypoglycemic episodes secondary to diabetes. Blood sugar would be within a range of 80 to 120. He would have relief of the episode within thirty minutes of interventions. Interventions listed were: -Labs as ordered, report abnormal findings to MD (medical doctor) with follow up as indicated. -Observe for excessive thirst, excessive eating, frequent voiding, change in level of consciousness, perspiration, fatigue, nausea/vomiting, tremors, provide interventions as per MD order monitor for effectiveness and report to MD if ineffective. -Monitor skin integrity. -Prompt activity attendance and mild exercise daily. -Monitor blood sugar levels per MD order and notify MD of abnormal findings as indicated. --Did not indicate he should have received juice, snack or what measures should have been taken when hypoglycemic episodes were present. --Did not indicate he should have received a bedtime snack. Observation on 8/27/18 at 5:35 p.m. of resident 53 during dinner in the Warren wing dining room revealed: He had a cup of coffee and a glass of ice water in front of him. He was served half a ham and cheese sandwich, tomato salad, and French fries. -He stared out the window and did not visit with the other residents at his table. -He did not attempt to eat his food. -When surveyor asked the residents at the table how supper was he replied slow. --He would not look at the surveyor; he just kept looking ahead out the window. At 5:57 p.m. he asked to go back to his room. The certified nurse assistant (CNA) walked him back to his room. -He was assisted with the use of a gait belt, a front-wheeled walker, and stand by assist from the CN[NAME] He drank approximately one fourth cup of his coffee and none of the ice water. He did not eat any of the food on the plate. Observation on 8/27/18 at 6:15 p.m. of resident 53 in his room after dinner revealed: The lights were on in his room. He had his eyes closed. He was laying on top of the covers with a blanket covering him. Review of the Interdisciplinary Progress Notes - Category Nursing for the following dates revealed: On 8/25/18 at 16:54 (4:54 p.m.) BS (blood sugar) checked, 59, OJ (orange juice) given will recheck. On 8/25/18 at 17:27 (5:27 p.m.) BS rechecked 74, supper is ready. On 8.26.18 at 10:00 (10:00 a.m.) at 0715(7:15 a.m.) CNA and writer (nurse documenting) went into resident's room to do wound care. Resident was very lethargic, not answering questions. Unable to focus on questions. Writer (nurse caring for resident) took his blood sugar and the reading was 52. Orange juice and sugar was given immediately. Blood sugar 10 minutes later was 79. Resident was more alert. At 0745 (7:45 a.m.) writer and CNA ambulated resident to the dining room using his walker and a gait belt. Resident ate all of breakfast and writer took blood sugar 250. Writer called PCP (primary care provider) to inform of blood sugar. Informed PCP office that another blood sugar will be taken at 1100 (11:00 a.m.). On 8/26//18 at 12:06 (12:06 p.m.) blood sugar at 1200 (12:00 p.m.) 114. Called PCP with blood sugar. Will have evening staff give an hs(night time/bedtime snack). On 8/26/18 at 17:15 (5:15 p.m.) Writer notified of resident on the floor .Denies any pain/discomfort .Assisted up to feet X (times) 2 assist. Resident was then assisted to dining room w/ (with) FWW (front wheeled walker), while resident was going to sit in dining room chair, resident missed the chair and landed sideways on him (L) (left) side. PCP was notified along w/ guardian, (guardian's first name). Monitor per protocol. -No documentation of the blood sugar for the above incident. On 8/28/18 at 00:14 (12:14 a.m.) Late entry for 8/27/18 21:25 (9:25 p.m.) nurse charting reported resident of having a blood sugar of 51 at 9:20 p.m. The physicians office was contacted and received an order to give [MEDICATION NAME] 15-full tube orally, check blood sugar every 10 minutes and to call back in 30 minutes if blood sugar levels not above 200. The tube of [MEDICATION NAME] 15 was given at 9:25 p.m. Blood sugar checked at 9:35 p.m. was 52. Blood sugar at 9:45 p.m. was 67. Blood sugar at 9:55 p.m. was 63. Called results to nurse practitioner caring for resident for this call and an order was given for an intramuscular injection of [MEDICATION NAME]. This injection was given at 10:02 p.m. and resident was rechecked at 10:05 p.m. resident was not responding as before and an order to transfer resident to the emergency room was obtained. -He was sent to the emergency room . -He had not returned to the facility during the survey. Review of the 8/25/18 to 8/27/18 Meal Intake Detail Report regarding resident 53's meal consumption revealed: On 8/25/18 he consumed 100% of breakfast and 75% of lunch. -There was no documentation for his dinner intake. On 8/26/18 he consumed 100% of breakfast, 75% of lunch, and 100% of dinner. On 8/27/18 he consumed 25% of breakfast and 50% of lunch. -There was no documentation for his dinner intake. Evening snack intake was recorded as he refused, he was sleeping, or he was offered and refused. Interview on 8/29/18 at 3:31 p.m. with the director of nursing regarding resident 53's occurrence of the above events revealed: He should have been encouraged to have an evening/bedtime snack or given some juice, so he would not be at risk for a hypoglycemic episode. A evening/bedtime snack was not ordered for him in the care tracker system. -She pulled him up in the computer to verify he was not triggered for a snack. -She identified maybe all diabetic residents should trigger for an evening/bedtime snack in the system. --At the time of survey all resident's would have been individually triggered for a snack by nursing or dietary staff. He was being watched closely because of his falls and low blood sugars. The physician was making changes to his medications. Review of the provider's (MONTH) (YEAR) Diabetes - Clinical Protocol policy revealed: The physician would order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff and physician would manage [DIAGNOSES REDACTED] appropriately. -There were no indications of amount of meal consumption needed to prevent [DIAGNOSES REDACTED]. -There were no indications when to hold anti-hyperglycemic medications.	2020-09-01
178	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-08-29	880	E	0	1	81NC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy review, and manufacturer's recommendations, the provider failed to: Follow manufacturer's instructions for disinfecting resident common use bathroom equipment by two of two observed housekeepers (A and B). Use appropriate hand hygiene during cleaning of resident rooms by one of two observed housekeepers (A). Maintain clean technique for one of four sampled residents (15) who used a Foley catheter bag. Findings include: 1. Observation and interview on 8/28/18 at 10:20 a.m. with head of housekeeping A revealed: She walked out of resident 41's room, discarded her gloves, and without performing hand hygiene she: -Put on a new pair of gloves. -Took a spray bottle with pH7Q Dual Disinfectant from the housekeeping cart. -Entered resident 30's bathroom. -Sprayed the contents of the above disinfectant on the sink. --The sink had a denture cup with tooth paste and an uncovered tooth brush in it. -Sprayed the hand rails and toilet. After ninety seconds she wiped the sink, hand rails, and toilet. With the same gloved hands she: -Put a roll of clear garbage bags on the housekeeping cart. -Returned to the above room and: --Moved the resident's drinking mug to another area on the night stand. --Straightened the papers on the night stand. --Swept the floor, mopped the floor, and placed a wet floor sign in front of the door. --Placed the resident's wheel chair in front of the bed. -Removed her gloves and did not perform any hand hygiene. Interview at that time with head of housekeeping A regarding the use of housekeeping chemicals and isolation procedures revealed: She did not know the contact time of the above disinfectant. She thought it was ten seconds. She was not sure what [MEDICAL CONDITIONS] infection of the bowel was or how to clean if they had it. They used Fuzion for deep cleaning resident rooms. She thought the contact time for Fuzion was ten seconds. 2. Observation and interview on 8/28/18 at 8:39 a.m. with housekeeper B outside of resident 22's room revealed: Without performing hand hygiene she: -Put on a pair of gloves. -Entered resident 22's bathroom. -Took the spray bottle with pH7Q Dual Disinfectant and sprayed the toilet and hand rail bars with it. -Took the container with the cleaning supplies back to the housekeeping cart. -Returned to the bathroom and began to wipe the sink, toilet, and hand rails with a clean cloth. Interview at the above time with housekeeper B regarding cleaning with chemicals and isolation procedures revealed she: Knew they had to use Fuzion for cleaning a room with [MEDICAL CONDITION] but did not know anything else about it. She had been employed in housekeeping for two months. She thought the pH7Q Dual Disinfectant contact time was ten to twenty seconds. 3. Interview on 8/28/18 at 1:09 p.m. with the administrator regarding the above observations and interviews revealed: Housekeeper A was the head of housekeeping. She would expect hand hygiene to have been done between changing of gloves. Housekeepers A and B: -Should have known the contact time of the housekeeping chemicals. Were educated on [MEDICAL CONDITION] during their general orientation training. Interview on 8/29/18 at 1:23 p.m. with the maintenance director regarding the above observations and interviews revealed: The current head of housekeeping had been trained by the former head of housekeeping on the correct contact times of the housekeeping chemicals used in cleaning residents' rooms. He would have expected the housekeepers to know the contact times of the housekeeping chemicals. The information for contact time was located on each housekeeping cart. Review of the provider's manufacturer's recommendation for the use of pH7Q Dual disinfectant revealed: Pre-clean heavily soiled areas. Apply use solution of 0.5% ounce of this product per gallon of water to disinfect hard, non-porous surfaces with a sponge, brush, cloth, mop, auto scrubber, mechanical spray device, coarse pump or trigger spray device. For spray applications, spray 6-8 inches from the surface. Do not breathe spray. Treated surfaces must remain wet for 10 minutes. Allow to air dry. Review of the provider's Clorox Fuzion Cleaner Disinfectant Spray per manufacture's recommendation revealed: The kill contact time for broad range disinfectant was one minute. The kill contact time for [MEDICAL CONDITION] spores was two minutes. Review of the provider's Housekeeping Daily Room Cleaning list had not included wearing gloves. Review of the signed 1/19/18 by housekeeper A Housekeeping Job Description revealed: The Housekeeper performs housekeeping and cleaning activities within well established guidelines and assigned areas. Cleans assigned areas, furnishings, and fixtures according to established housekeeping procedures. Review of the undated Cleaning and Disinfection of Environmental Surfaces policy revealed Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products. Review of the provider's 1/11/18 Hand Hygiene policy and procedure revealed To reduce the transmission of organisms and prevent the spread of infection, hand washing and/or hand sanitizing must be done prior to when hands are visibly soiled, after using the restroom, before and after glove use. 4. Observation on 8/27/18 at the following times in resident 15's room revealed at: 3:13 p.m.: -An uncovered Foley drainage bag was laying on the floor beside his bed. 5:18 p.m.: -Certified nursing assistants (CNA) C and D: --Entered his room. --Placed a sling for the mechanical lift under him. -The Foley catheter drainage bag was on the floor. -CNA D stepped on the bag, looked down at the bag, and without wiping it off, layed it on the bed, and continued to transfer resident 15 with CNA C helping. -After the resident was in the electric wheelchair the uncovered catheter bag was placed on the foot rest of the electric wheel chair behind his legs. Interview on 8/29/18 at 11:04 a.m. with the administrator regarding the above observation revealed: The Foley catheter drainage bag was not to be on the floor. CNA D should have disinfected the Foley catheter drainage bag before placing it on the bed. Interview on 8/29/18 at 11:18 a.m. with the director of nursing regarding the above observation revealed: The Foley catheter drainage bag should not have been on the floor. They should have cleaned or disinfected the Foley catheter drainage bag before laying it on the resident's bed. 5. Interview on 8/29/18 at 1:36 p.m. with the infection control nurse (ICN) revealed: New employee's were educated on infection control policies and procedures. Hand washing had been included in the new employee training. They were educated on the hand hygiene policy and procedure in general orientation. The new employee orientation packet for new staff had a sheet that indicated the staff had acknowledged they received the above information. She monitored new staff on hand hygiene, and when they were competent she documented that on a check off sheet that was located in the back of their personnel file. She would have expected the housekeeper to change gloves and do hand hygiene in between cleaning of the toilet and before starting a new task in the resident room. Foley bags: -Were not to be on the floor. -They were to be attached to the bed. She would have expected the Foley catheter drainage bag to have been cleaned or disinfected before placing it on the bed. The ICN gave the new housekeeping staff the Housekeeping Department Use of Chemicals Procedure. Review of the provider's (MONTH) (YEAR) Catheter Care, Urinary policy revealed: *Infection Control: -2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. --b. Be sure the catheter tubing and drainage bag are kept off the floor.	2020-09-01
179	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	550	E	0	1	SJ6G11	Based on observation, interview, and policy review, the provider failed to ensure dignity and privacy was maintained while being assisted with personal care and medication administration through an alternative route for three of five sampled residents (11, 31, and 74). Findings include: 1a. Observation and interview on 10/15/19 at 1:34 p.m. of resident 74 revealed: He had: -Been in his room sitting in a wheelchair (w/c) watching television (TV). -A urinary catheter collection bag hanging underneath of the w/c. That collection bag had: -Been full of cloudy and yellow colored urine. -No dignity cover over it and was visible to the staff and visitors walking by in the hallway. He stated: -I'll be going to bingo pretty soon. -I also have a doctor's appointment sometime today too. Observation and interview on 10/15/19 at 3:28 p.m. of resident 74 revealed: He had been sitting in his w/c by the east wing nurses' station. An unidentified staff member offered to assist him back to his room. His urinary catheter collection bag continued to not have a dignity cover over it and was visible to the staff and visitors in that area. Observation on 10/15/19 at 3:31 p.m. with certified nursing assistants (CNA) M and P with resident 74 revealed: The resident had been in his room sitting in his w/c. They had prepared to assist him with personal care and transfer onto his bed. After the CNAs assisted the resident with laying down on his bed CNA M attached his collection bag to the bed frame on the side of his bed. His urine collection bag remained uncovered and visible to all people walking by in the hallway. The CNAs had made no attempt to cover the urine collection bag prior to leaving his room. b. Observation on 10/15/19 at 4:57 p.m. with CNAs M and P with resident 11 revealed: The resident had been laying on his bed sleeping. There had been a large window in his room. The window had no privacy covering over it and faced out towards a large courtyard. There had been a folded up window blind on the floor propped up against the dresser. CNAs M and P had prepared to assist him with personal care and transfer from the bed into a w/c. Without covering the window for privacy the CNAs: -Pulled down his pants and assisted him with personal care. -Transferred him from the bed into a w/c with the use of a mechanical transfer lift. c. Interview on 10/15/19 at 5:13 p.m. with CNAs M and P regarding the above observations revealed: They confirmed both of the residents required staff support and assistance with ADLs (activities of daily living). -That had included covering the urinary collection bags and covering windows during personal care. CNA M stated: -(Resident 74's name) actually has a cover for his bag on his stand by the bed. -We should have made sure it was on. They: -Had been aware the window covering in resident 11's room was not on his window. -Agreed the window should have been covered prior to assisting him with personal care and a transfer. CNA P stated: -We are supposed to put in a note to maintenance when things like that need fixing. -At night we just hang a sheet or blanket over his window for privacy. -His window has been like that for a while. d. Observation on 10/17/19 at 8:23 a.m. with licensed practical nurse (LPN) K with resident 31 revealed: The resident had been laying on his bed, awake, and watching TV. His bed had been positioned by the window. -That window had no privacy covering attached to it. LPN K had prepared to assist the resident with his medications. He had swallowing difficulties and required the use of a feeding tube to take his medications. LPN K: -Pulled up his shirt to expose his abdomen and feeding tube. -Administered his medications through the feeding tube. -Had not attempted to cover his window during the medication administration to ensure his dignity and privacy was maintained. Interview on 10/17/19 at the time of the above observation with LPN K revealed she: Agreed his privacy and dignity was not maintained during the administration of his medications and should have been. Stated: -He's had a blind on that window in the past, I'm not sure what happened to it. -I'll put a note in for maintenance to fix it. e. Interview on 10/17/19 at 1:53 p.m. with the maintenance assistant S regarding the window coverings for residents 11 and 31 revealed he: Had observed some of the windows that had missing blinds or window coverings for them. Would have replaced one or two blinds on the windows weekly. Stated: -I don't know, they just fall down or come off. -When something is broken or needs fixed the staff are supposed to fill-out a request and put it in the box by our room. -I don't check those routinely, no. Agreed the windows should have some type of privacy covering over them to make sure dignity was maintained. Interview on 10/17/19 at 2:10 p.m. with the director of nursing and the administrator regarding the above observations revealed they: Had: -Not been aware of all the privacy concerns identified above. -Recently been informed about the missing window coverings and were in the process of having those put back on. Would have expected the staff to have: -Ensured resident 74's urinary catheter collection bag had been covered at all times. -Made sure the windows were covered to maintain resident privacy and dignity during ADLs. Review of the provider's 7/6/15 Quality of Life -Dignity policy revealed: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Staff shall promote, maintain and protect resident privacy and dignity, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: Helping the resident to keep urinary catheter bags covered.	2020-09-01
180	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	565	D	0	1	SJ6G11	Based on interview, record review, and policy review, the provider failed to ensure residents' concerns voiced in resident council meetings were resolved. Findings include: 1. Interview on 10/16/19 at 10:30 a.m. with members of the resident council revealed: They met monthly with staff assisting in the arrangements of the meetings. -Social worker (SW) W was always present and led the meetings while the activity director took the minutes. -Other staff came to the meeting that represented the department they might be discussing such as the dietary staff would come in to talk about food related issues. There were always food or dietary related concerns including: -Not feeling like their individual concerns were being honored. -They had repeatedly asked for fresh fruit but never received any. -They ran out of coffee on more than one occasion. -In the east dining room they had to wait too long for coffee, because staff would not serve it until they had all the residents in the dining room. -They did not like the small glasses that were used, because they were tippy. -They wanted a salad bar with more items than just lettuce and tomatoes. They were frequently told their dietary requests could not be accommodated, because the item was on back order. SW W was their voice, but they did not feel the concerns were followed-up on. They felt there were always excuses for why their requests were not honored. They did not feel the staff tried to resolve the concern, but that they would tell them why something was not available. The dietary department was well aware of those above concerns. Review of the provider's 10/14/19 through 10/20/19 one week menu cycle revealed a fresh fruit was only indicated once. Interview on 10/16/19 at 3:29 p.m. with dietary managers (DM) A and B revealed: They confirmed there were always multiple concerns about individual food preferences. For a stretch of time there were financial restraints with the previous owner, so they did not have any food truck deliveries. -There were times they had to pinch hit with food, but they always had food to feed the residents. They had run out of coffee once because their coffee had to be frozen. The staff had taken it out of the freezer, and it had to be disposed of. -They denied they had run out of coffee more than once. --They confirmed the residents in the east dining room might have had to wait for coffee, because the coffee maker in that dining room had broken down several times. --They always had it repaired, but that had been a repeated issue. In the recent past they had financial issues, so they were not always able to get fresh fruit because of the cost. -They always had bananas and oranges but the residents would not always eat them. -They would end up throwing them away or making banana bread out of it. In the past a salad bar had not been an option. -They were hopeful they might be able to start one now, but they had also had problems with the lettuce getting frozen and then becoming soggy. When there were dietary complaints in resident council the DM would go to the meeting and try to respond to them in person. DM B: -Talked about individual requests that were difficult to satisfy because of either budgeting issues or the resident not eating the item once they received it. -Also talked about a resident who wanted an item but if they gave into that request she would over indulge in it, and it was not appropriate for her diet. --She did not address the resident's right to be informed and make a decision based on the risk or benefit. During the interview DM B always explained why something had not been available, but she did not explain what they were doing to resolve it. Interview on 10/17/19 at 11:30 a.m. with the resident council president revealed: The way the above meeting had gone was the way all meetings went. -There were multiple residents with concerns. He felt it was a good process. Random review of Resident Council meeting minutes revealed: 8/21/19: -Residents requested banana splits, craft kits, and knitting. -Each response was when they could get the supplies. -Residents noted they had not had new activity supplies for quite some time. -Were told they would order supplies when they were able to do so. -Eggs were cold and rubbery when they received them in the morning. --The response was, Doing fried eggs for breakfast is very tricky. This is why we quit doing them everyday. 9/23/19: - Resident wondered if he could take leftovers to his room. --He was told he could not due to the monitoring that would need to have been done. -Resident requested chocolate creamers, but was told they had thrown too many away so they would not be ordering them anymore. Interview on 10/17/19 at 9:00 a.m. with SW W regarding the above Resident Council meeting minutes revealed: They followed-up after each meeting at the next meeting of the previously identified concerns. He agreed they had many repeat concerns from month-to-month including the above mentioned dietary concerns. He felt the DM tended to take the concerns personally and wanted to defend the reasons not changed, because some of those issues had been out of her control. Review of the provider's 10/23/13 Resident Council policy revealed: (Facility name) supports residents' desires to be involved and have input in the operation of the facility through the Resident Council. *Procedure: -The purpose of the Resident Council is to provide a forum for: --Residents to have input in the operation of the facility; --Discussion of concerns; --Consensus building and communication between residents and facility staff; and --Staff to disseminate information and gather feedback from interested residents.	2020-09-01
181	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	584	E	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure a clean and homelike environment was maintained for: Two of three randomly observed floor mats positioned by the residents' (11 and 29) bed. The counter top on one of three nurses' station desk area (east wing). The window coverings in five of ten randomly observed residents' rooms (211, 313, 319, 321, and 327) were in place or good repair. Five of seven randomly observed residents' shared bathrooms (228, 302, 304, 319, and 326) was clean and in good repair. Three of three observed mechanical transfer lifts (east wing and central wing) were clean. One of eight randomly observed resident's (4) wheelchair (w/c) was clean and in good repair. The carpet on one of three wings (east) was clean and in good repair. The ceiling tile on one of three wings (east) was clean and in good repair. Multiple metal brackets holding the ceiling tile in place for one of three wings (east) had cleanable surfaces. Three of four observed exit doors on one of three wings (east) were clean. Three of six randomly observed ceiling vents were clean and free from debris on one of three wings (east). Findings include: 1a. Random observations on 10/15/19 from 1:23 p.m. through 2:48 p.m. of residents 11 and 29's rooms revealed: They were both resting in their beds. Their beds were in the lowest position. There were cushioned floor mats on the floor by their beds. -Those floor mats had multiple cracks on the surface of them and exposed the cushioned material inside of them. -Those cracks had created an uncleanable surface for those floor mats. b. Observation on 10/15/19 at 1:34 p.m. of the east wing nurses' station revealed: The counter top on the nurses' desk had multiple chipped areas along the bottom edge. Those chipped areas had exposed the pressed wood underneath of the protective covering. Those missing chips had created an uncleanable surface for the nurses' station. c. Random observations on 10/15/19 from 1:53 p.m. through 2:18 p.m. and on 10/16/19 at 8:34 a.m. of the following residents' windows in their rooms revealed: room [ROOM NUMBER] was a shared room with one large window in the room. -That window had no window covering attached to it for privacy during personal care for the resident. room [ROOM NUMBER] had blinds covering his window. -That blind had two strips that were broken in half. room [ROOM NUMBER] had two large windows in her room, but only one window was covered with a blind. -The other window had no window covering attached to it. There had been a white thin blanket handing on the left side of it. room [ROOM NUMBER] had two windows in his room covered with blinds. -The bottom of one of the blinds was bent in an upward position. room [ROOM NUMBER] had one large window with no window covering to ensure privacy occurred during personal care. d. Random observations on 10/15/19 from 1:23 p.m. through 4:45 p.m. and on 10/16/19 at 10:24 a.m. of the following residents' bathrooms revealed: room [ROOM NUMBER]: -Was a shared bathroom with room [ROOM NUMBER]. -Had a white substance covering the entire floor surface and wall board behind and beside the toilet. room [ROOM NUMBER]: -Was a shared room with 325. -The toilet was sitting on a large wooden base. The paint had been chipping off, and there were several gouges in the wood. Those gouges and chipped paint created uncleanable surfaces. -The cover for the tank was not the same shape as the tank and did not cover the opening for the holding tank. -The floor in the bathroom was not clean and had dirt collecting in all of the corners. Surveyor: Observation on 10/16/19 at 4:40 p.m. and on 10/17/19 at 4:10 p.m. of the bathroom shared by resident rooms [ROOM NUMBERS] revealed: There was three non-slip strips in front of the toilet that had an unidentified dark smeared substance between the strips. The caulk around the toilet was missing, and the caulk that was there was discolored and looked dirty. There were dark spatters on the toilet base that appeared to be feces. The floor was dull and appeared to have dirt in the grout of the floor. The cement base to the toilet appeared to be painted gray and was worn off in several areas. The screen to the window was torn, and there were large spider webs between the screen and the window. Observation on 10/16/19 at 4:30 p.m. of resident room [ROOM NUMBER] bathroom revealed: -The floorboards around the toilet were soiled. -There was missing caulk around the toilet. -There was also a broken tile in the floor which left the floor an uncleanable surface. Observation on 10/16/19 at 4:50 p.m. and on 10/17/19 at 4:00 p.m. in room resident 304 revealed: The base pedestal the toilet sat on was too small. The toilet base was deteriorating; it looked like moisture had gotten between the base and the floor with a plaster type material coming out of the cracks. There were several spots of exposed drywall making them an uncleanable surfaces. There were missing floor tiles and the floor appeared soiled. One of the cupboard doors as you first entered his room was falling off the hinge and hung down. Surveyor: 2. Random observations on 10/15/19 from 1:20 p.m. through 6:10 p.m. of three mechanical transfer lifts revealed: On east wing there had been two mechanical transfer lifts across from the nurse's station. -Those lifts had bases attached to them so the residents could stand-up during a transfer. -The base on those lifts had a thick layer of dirt and food particles on it. On central wing there had been a mechanical transfer lift in their hallway storage area. -That lift: --Had a base attached to so the residents could stand-up during a transfer. --Had the same observation as those above. 3. Observation on 10/15/19 at 2:23 p.m. of resident 4's electric w/c revealed: The foot rest was dirty with brown and white particles on it. The corners and protective covering for the foot rest was torn and coming off. -Those torn areas had created an uncleanable surface. 4a. Observation on 10/15/19 from 1:35 p.m. through 6:27 p.m. of the east wing carpeted area revealed the carpet: Was discolored with gray and white spots in multiple areas. -That discoloration gave the carpet a soiled appearance. -Had come unattached from where it met up with the wood flooring close to the nurses' station. --It was frayed and torn along the entire edge. -Had dirt and paper particles throughout the entire area that gave the appearance it had not been cleaned. b. Random observations on 10/15/19 from 1:35 p.m. through 5:45 p.m. of the ceiling tile and the metal brackets on the east wing revealed: That tile was in the shape of squares and was held in place by metal brackets. That tile was warped and did not fit properly in the metal brackets in multiple areas. -Those gaps had created openings directly into the ceiling of the building. The metal brackets holding the tile in place was rusted in several areas. -Those rusted surfaces had created uncleanable surfaces. e. Random observations on 10/15/19 from 1:35 p.m. through 5:20 p.m. of the ceiling vent grates on the east wing revealed three of those vents were dirty with a thick layer of gray colored lint on them. d. Random observations on 10/15/19 from 2:10 p.m. through 5:50 p.m. of the east wing exit doors revealed: Two of the exit doors by rooms [ROOM NUMBERS] had: -A collection of dirt built up on the thresholds that a line could be drawn through it. -The corners on both sides of those exit doors had cobwebs with dirt particles and dead bugs in them. The exit door leading out into the residents' courtyard had the same appearance as the ones observed above. 5. Interview on 10/16/19 at 8:23 a.m. with maintenance assistance S revealed: His supervisor had currently been gone on personal leave. He was not aware of all the concerns identified above. He stated: -I replace the blinds as I see them and as the staff tell me. -But sometimes I replace a blind and next thing it's falling off again. -We do rely on them to fill out work orders for anything that needs repairing. -I did hear that process was changing soon so a computerized program. -The housekeepers are responsible for making sure the rooms, hallways, storage rooms, and bathrooms are kept clean. -I'm not sure about a preventative maintenance program. We do have a lot of folders in our room, but I mostly rely on what my boss tells me to do. -I don't do routine checks on the lifts, but I think my boss does. -I'm not sure on the cleaning of them. He would have fixed w/c concerns as he observed them or as the staff had requested it. Interview on 10/16/19 at 10:12 a.m. with housekeeper V regarding the observations above revealed: Everyday was considered a deep cleaning day for the residents' rooms. She would have moved the beds and furniture and did a deep clean on their rooms daily. She was not aware of any other day assigned or scheduled for deep cleaning. The carpet would have been vacuumed twice a day. Interview on 10/17/19 at 2:10 p.m. with the director of nursing and the administrator revealed they: Had not been aware of all the concerns identified above. Confirmed the night shift was responsible for the cleaning of the mechanical transfer lifts. -There had been a schedule for them to follow for each day of the week. -Those schedules were to have been signed by the staff as the tasks were completed. Confirmed there were several days in a week when there was no documentation from the night shift staff to support w/c cleaning and mechanical lift cleaning had occurred. Had observed several areas of concern identified above with the new owners during a walk-through in (MONTH) (YEAR) and prior to the purchase of the facility. -At the time of that walk-through all the above areas of concern identified had been observed. Confirmed the housekeepers would not have completed a deep cleaning everyday and were to have checked with the nurses first. Agreed the areas of concern identified above were not a clean and homelike environment for those residents to live in. Review of the provider's 3/22/17 Quality of Life - Homelike Environment policy revealed: Residents are 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 shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: -Cleanliness and order, -Inviting colors and decor.	2020-09-01
182	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	604	D	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled resident's (11) had assessments and documentation to confirm his movement was not restricted: With the use of a Pummel cushion when sitting in his wheelchair (w/c). When a wedged pillow was placed underneath of his mattress when resting in his bed. Findings include: 1. Observation on 10/15/19 at 2:48 p.m. of resident 11 revealed: He had been: -Laying in his bed sleeping. -Positioned on his left side and was facing the wall. His bed had: -Been pushed up against the wall on the left side. -Been in a low position and was close to the floor. -A floor mat positioned on the floor next to the bed. There had been a wedged cushion placed underneath of his mattress on the right side of his bed. That wedged cushion had: -Been positioned in the middle of the bed. -Created a large raised area behind the resident's lower back and bottom. Review of resident 11's undated pocket care plan information revealed: He was to have a reposition pad in his w/c. His bed was to have been in the low position and a floor mat next to the bed. A foam noodle was to have been placed underneath the mattress. Observation on 10/15/19 at 4:57 p.m. of certified nursing assistants (CNA) M and P with resident 11 revealed: He continued to lay in bed as observed above and had not made any noticeable change in position. The CNAs prepared to assist him with personal care and a transfer from the bed to his w/c. In his w/c was a Pummel cushion that had a raised area. The raised area: -Was located in the middle of the cushion and between his thighs. -Prevented him from scooting forward in the w/c. Interview on 10/15/19 at 5:13 p.m. with CNAs M and P regarding the wedged pillow and Pummel cushion used by resident 11 revealed: They confirmed the resident had a history of [REDACTED]. The wedged cushion was used to keep him from falling out of his bed. CNA P stated: -That's a restraint isn't it? -We put it in there (wedged cushion) to stop him from getting out of his bed. -If we don't he'll be right on the floor. They were not sure what the special cushion in his w/c was used for. They used the pocket care plans to ensure the proper care was provided for the residents. They were unsure how they were updated or who updated them. Review of resident 11's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED]. He was dependent upon the staff to assist him with all activities of daily living (ADL) and anticipate his needs. His memory recall was poor with little to no safety awareness. There was no documentation or assessments to support: -He did not have the capability and strength to properly position himself when sitting in a w/c. -He required the use of a Pummel cushion in his w/c to ensure his positioning needs were met. -The therapy department had reviewed the resident, and they supported the need for the Pummel cushion in his w/c. -Why he had required the use of a wedged pillow or foam noodle underneath of his mattress when laying in his bed. -The wedged pillow, foam noodle, and Pummel cushion were not restricting his movement when in bed or the w/c. -His primary physician had written an order for [REDACTED].>-His representative had given permission for the use of those devices. Review of resident 11's comprehensive care plan revealed: Multiple initiated and reviewed dates for focus areas and interventions. He had a focus area supporting he was at risk for falls that was initiated on 8/31/17. The interventions for that focus area had been: -Hi/low bed will be in lowest position. -Scoop mattress on bed. -Fall mat on floor next to bed when resident in bed. -No intervention to support the use of a wedged cushion or foam noodle underneath of his mattress. No documentation he required the use of a Pummel cushion when sitting in his w/c. Review of resident 11's 8/1/19 annual Minimum Data Set (MDS) assessment, section P revealed he had not required the use of a bed or chair restraint. Review of resident 11's 8/6/19 annual MDS summary confirmed he had a history of [REDACTED]. -Did not have the capability to properly support himself when sitting in a w/c and required the use of a device to assist him with that. -Had poor safety awareness and required the use of a wedged cushion or foam noodle under his mattress to ensure his safety had occurred. Interview on 10/17/19 at 11:23 a.m. with the director of nursing (DON) and the administrator regarding resident 11 revealed they: Confirmed the resident had a history of [REDACTED]. The pocket care plan was not considered a part of his care plan. -It was a quick resource for the staff to use. -All of the management team were responsible for updating them. -That information should have been found on his comprehensive care plan. Were not aware the staff had been placing the wedged cushion underneath of his mattress. -That cushion was to have been placed directly behind his back. Confirmed he required the use of a Pummel cushion: -For postural support. -To prevent him from scooting down and falling out of the w/c. Agreed: -There should have been documentation and assessments in his chart supporting the use of those devices. -Those devices had the potential for restricting his movements and without supporting documentation for them they had been considered restraints. The surveyor had requested any and all documentation the DON and administrator could find to support the use of those devices for the resident. No further documentation was provided to the surveyor prior to the exit from the facility on 10/17/19 at 6:15 p.m. Review of the provider's (MONTH) (YEAR) Use of Restraints policy revealed: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. Treat the medical symptom. b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well-being. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). Physician order [REDACTED]. a. The specific reason for the restraint. b. how the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). *Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the physical restraint. b. A description of the resident's medical symptoms that warranted the use of restraints. c. how the restraint use benefits the resident by addressing the medical symptom. d. The type of physical restraint used.	2020-09-01
183	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	610	E	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, policy and procedure review, the provider failed to ensure a thorough investigation had been completed and documented for two of two sampled residents (34 and 73) who had a fall with injury. Findings include: 1. Review of resident 73's medical record revealed: admission date of [DATE]. She had been admitted on Medicare part A/skilled nursing. She had been receiving occupational therapy (OT) and physical therapy (PT) services with a goal to return home. The undated Admission Observations flow sheet stated she required assist of 2 with transfers. Review of the admission 9/5/19 Minimum Data Set (MDS) assessment for resident 73 revealed: A Brief Interview for Mental Status assessment score of fourteen indicating she was cognitive. She required: -Extensive assistance of two staff members with transfer and toilet use. -Limited assistance of one staff member with ambulation. Interview on 10/16/19 at 4:03 p.m. with resident 73 revealed: She had gone to the hospital on [DATE] from her own home, because she woke up and could not walk. They sent her to the nursing home around 9/1/19 for occupational therapy and physical therapy. On 9/14/19 a staff member had been assisting her to the bathroom. -They had placed a gait belt on her and were assisting her with the walker. -The staff member let go of her, walked around her, and opened the bathroom door. -She fell backwards to the floor hitting the back of her head. -They sent her to the hospital. -She ended up with a bump to the back of her head and had broken her right collar bone. -She would be resuming therapy services on 10/23/19. Continued interview on 10/17/19 at 10:30 a.m. with resident 73 regarding her fall on 9/14/19 revealed the same story as she had said above. Review of the South Dakota Department of Health required healthcare facility event reporting final report for resident 73 revealed:Cognition score of fourteen indicating she was cognitive. Brief explanation of the above event being reported was: -Resident had a fall on 9/14/19 at 1000 (10:00 a.m.). -She stated she hit her head on her built in dresser as she fell backwards. -Has a bump to the back of her head. -Right clavicle was pushed forward. -Vitals stable and neuros (neurology signs) within normal limits. -MD (medical doctor) notified of bump to head and clavicle disposition and ordered to send to ER (emergency room ) for evaluation. -Family notified and (resident name) sent via ambulance to the ER. Conclusionary summary of facility investigation for the above: - Allegation of abuse/neglect unsubstantiated. -X-ray to clavicle shows that R (right) clavicle is fractured. -Fall was witnessed by RN (registered nurse). -It appears that (resident name) lost her balance while walking into the bathroom. -Therapy notified to see if any other evaluations needed for treatment due to balance. -Care plan and pocket care plan updated to have supervision to 1 assist with ADL's (activities of daily living) and walking related to balance. Review of the facility's 9/14/19 Fall Report for resident 73 revealed:Time of fall was 10:00 a.m. The fall had occurred in her room. It had been witnessed by RN U. RN U had documented:-RN assisting resident to bathroom for BM (bowel movement) when she lost her balance and fell backwards into wardrobe. Large hematoma noted immediately to back. -Resident interview: I just lost my balance. Just my head hurts. (Later stated pain to clavicle). Nursing assessment regarding the cause for the fall and interventions: -Resident lost balance. Review of the 9/13/19 and 9/14/19 interdisciplinary progress notes for resident 73 with the following dates revealed on: 9/13/19 at 2:40 p.m.: -In PT she is walking 100 feet and stairs. -Plan is to continue to strengthen the leg, work on balance and stairs, dressing and toileting. 9/14/19 at: -5:26 p.m.: Writer was helping resident to restroom in her room when she fell backwards and hit her head on the wardrobe. --Writer had just gotten pt (resident) up from recliner using gait belt and FWW (front wheel walker). --Resident was standing and lost her balance tripping backwards. -5:29 p.m.: X-ray to clavicle shows that R clavicle is fractured. Review of the 9/12/19 through 9/19/19 OT notes for resident 73 revealed on: 9/12/19: -Goal: toileting:--Current level of function: Completes toilet transfers with CGA (contact guard assist), toileting tasks requiring minimal assistance. Goal date 9/26/19. -Goal: Activity tolerance while standing:--Maintains functional standing postural alignment and balance for 7 minutes, limited primarily by a deficit in standing balance self cares at stand with minimum assistance. Goal date 9/26/19. -Remaining functional deficits/underlying impairments: --Patient has the following remaining impairments impacting function: standing balance, activity tolerance, safety with 4WW. -Precautions: Chronic R knee pain, low back pain, fall risk. 9/19/19: -Goal: Activity tolerance while standing: --Maintains functional standing postural alignment and balance for 4 minutes, limited primarily by a deficit in standing balance, impacting ability to complete selfcare at stand with minimum assistance. Goal date 9/26/19. Review of the 9/13/19 through 10/1/19 PT notes for resident 73 revealed on: 9/13/19: -Impact on burden of care/daily life: --Patient continues to be at high risk for falls with needing CGA for sit to stand and surface to surface with walker with CGA with ambulation. -Precautions: --Balance precautions include fall risk, chronic low back and R knee pain. 9/20/19: -Other notations: --Patient has had a decline in function this week as she had a fall this week hitting her head and fx (fracture) R clavicle, is now non weight bearing RUE (right upper extremity) and wearing sling RUE. 10/1/19: -Impact on burden of care/daily life: --Nursing reports patient is now able to participate with TRANSFERS WITH CGA in room. Review of the 9/14/19 emergency department report for resident 73 revealed a [DIAGNOSES REDACTED]. Review of the updated care plan for resident 73 with the following dates revealed: 9/10/19: -Problem: At risk for falls related to weakness, decreased mobility, and right knee and back pain. -Interventions: --Will receive assistance with transfers to reduce the risk of falls. --Will receive assistance with locomotion. --Will receive assistance walking to reduce the risk of falls. --Mobility devices/equipment FWW and w/c. -Problem: Activities of Daily Living: -Interventions: --Resident transfers with assist of one and uses a FWW. --Use gait belt for all transfers. --Provide assist of one for personal hygiene. Interview on 10/17/19 at 2:00 p.m. with the administrator and the director of nursing (DON) regarding resident 73's fall on 9/14/19 revealed: They had relied on the nurses for the fall reports. The nurse who had been assisting her during the fall was RN U. -She was a new nurse. -She had been employed less than a month. They had not asked the resident what had happened during the investigation. They agreed the resident was cognitive. -They should have asked the resident during their internal investigation what had happened They agreed the two stories had not collaborated. The fall had impacted the resident's therapy. They had not done a thorough internal investigation of the resident's fall. 2. Review of resident 34's medical record revealed: He was admitted on [DATE]. His Brief Interview for Mental Status assessment score was thirteen indicating he was cognitively intact. He had a [DIAGNOSES REDACTED]. Her required one assist with a pivot transfer. On 6/14/19 he had a fall resulting in a [MEDICAL CONDITION] and was transferred to the emergency room . Interview on 10/16/19 at 5:00 p.m. with resident 34 revealed: He was alert and oriented to person, place, and time. He could communicate his needs without difficulty. There were times when staff made him angry because of their tone of voice when they came to help him. -They would say What do you want?, and he did not like that approach. Review of resident 34's 9/14/19 fall investigation revealed: Brief explanation: The writer was notified that (resident's name) was found on the floor on 9/14/19 at 2030 (8:30 p.m.) between his wheelchair and his bed on his left side with a laceration to the left side of his head. Pressure applied to laceration, vitals obtained and stable and neuros within normal limits. -Resident was sent to the emergency room for an evaluation. A hand-written note by the certified nursing assistant that found him with a first name only read: It was 8:15 When one was taking the laundry when one saw (resident's name) right at the door on the floor. And blood was coming from his head. When one ask him what he was doing he told me that someone make him so bad from yesterday till today so he was trying to get up to meet with the person he fell . Conclusionary summary: Allegation of abuse/neglect unsubstantiated. -It was signed by the administrator. There was no further evaluation of: -Who was he wanting to meet with? -Why had he not asked for assistance? -Was it a staff person who had upset him? Interview on 10/17/19 at 2:22 p.m. with the DON revealed regarding resident 34's above fall investigation revealed: She and the administrator were responsible for making sure investigations were completed thoroughly. She confirmed that investigation had not been thoroughly completed, because there were unanswered questions about what had upset him leading to a self-transfer and fall. Interview on 10/17/19 at 2:30 p.m. with the administrator regarding resident 34's above fall investigation revealed she: Had reviewed that fall investigation. Could not address what or who had upset the resident, particularly if it had been a staff person. Confirmed that investigation had unanswered questions and had not been completed thoroughly. 3. Review of the provider's 11/28/17 Abuse and Neglect policy revealed: Investigation: Have procedures to: -Investigate all allegations of abuse, neglect, exploitation, and misappropriation of property. -Identify staff responsible for investigation. All allegations will be investigated by the Administrator or Designee immediately. -Interview all involved person including victim, perpetrator, witnesses, and other who might have knowledge of the allegation. -Thorough documentation of the infestation. Surveyor Review of the provider's (MONTH) 2019 Falls - Clinical Protocol policy revealed: 5. The staff will evaluate and document falls that occur while the individual is in the facility. Review of the provider's (MONTH) 2019 Assessing Falls and Their Causes procedure revealed: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. 2. Defining Details of Falls: -a. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred.	2020-09-01
184	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	641	D	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and manual review, the provider failed to ensure one of two sampled residents (58) who required [MEDICAL TREATMENT] services three times a week had been accurately recorded on the Minimum Data Set (MDS) assessment. Findings include: 1. Review of resident 58's medical record revealed: She was admitted on [DATE]. Her primary admission [DIAGNOSES REDACTED]. She had required [MEDICAL TREATMENT] services for her [MEDICAL CONDITION] three times a week. Her most recent 9/13/19 quarterly MDS was coded to support she had not required any [MEDICAL TREATMENT] services. -The 9/23/19 nursing summary of that MDS had not supported the need for [MEDICAL TREATMENT] services three times a week. Observation and interview on 10/16/19 at 10:24 a.m. with resident 58 revealed she: Had been in her room resting in the recliner. Was alert, oriented, and capable of making her needs known. Stated: -I just got back from [MEDICAL TREATMENT], so I'm resting a bit. -I go every Monday, Wednesday, and Friday. Had a shunt for [MEDICAL TREATMENT] placed in her upper left arm. Interview on 10/16/19 at 10:31 a.m. with registered nurse (RN) R regarding resident 58 revealed he: Confirmed the resident went for [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Would have assessed her shunt site on the days she went out for [MEDICAL TREATMENT]. Interview on 10/17/19 at 10:35 a.m. with the director of nursing revealed she: Confirmed the resident had a [DIAGNOSES REDACTED]. Would have expected: -That to have been accurately coded to support that. -The Resident Assessment Instrument manual to have been followed for MDS coding. Review of the (MONTH) (YEAR) Centers for Medicare and Medicaid long-term care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.16, revealed: *Page O-4 related to section O0100J, [MEDICAL TREATMENT], included: -Code peritoneal or [MEDICAL TREATMENT] which occurs at the nursing home or at another facility, record treatments of hemofiltration, and Continuous Ambulatory Peritoneal [MEDICAL TREATMENT] in this item.	2020-09-01
185	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	657	E	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure 3 of 24 sampled residents (11, 50, and 235) had a revised and updated care plan to reflect their current needs. Findings include: 1. Interviews and observations on 10/15/19 at 3:00 p.m. and on 10/16/19 at 9:45 a.m. of resident 50 revealed she: Was alert and oriented to person and place. Laid on her bed with no clothes on except a disposable brief. -Showed no discomfort with herself being undressed and surveyors presence. Stated loudly, This place sucks and went on to say how unhappy she was at the facility. -Felt like she was just put in the facility to die, and all the staff cared about was getting her money. -Did not care how she got out of there, but thought it would take dying to get out. -Did not go to any activities and emphatically stated did not care to go. -Did not know who the social worker was or that she had a social worker to visit with. -Had a computer she thought she should bring into her room but did not know where it was. -Went to the dining room for breakfast and lunch but not supper. --Did not visit with any peers and was unhappy with the other residents in the dining room. Interview on 10/17/19 at 7:48 a.m. with certified medication aide D regarding resident 50 revealed she: Did not like to get dressed, and laid in bed without any clothes on. Got upset about being here and cried. Could get upset about little things like just wanting to get a can of pop. She was not always cooperative with her bath. She had never seen any visitors. Review of resident 50's social services notes revealed: 6/25/19: She scored a 6/27 on the pHQ9 (an assessment of depression) indicating depression concerns at this time. She expressed that she feels this is as she has no control of her situation and has no one as intelligent that she is able to interact with her. 7/2/19: Care conference summary: -Resident had refused to participate in the care conference. -She had refused every attempt to weigh her. -Her food intake varied depending on her mood. -Refused all structured activities but did like one-to-ones. -A medication for her mood and anxiety had been increased by her physician since her admission. -She continued to be unhappy with multiple things but was unwilling to give specifics. 7/24/19: The social worker went to speak with her about her emotional state offering a mental health counselor, but she declined. -She became tearful and stated she did not want to be there anymore. -Discharge was discussed with her, but she stated she had no where to go. Interview on 10/17/19 at 9:30 a.m. with the director of nursing (DON) regarding resident 50 revealed: She liked to be in her room undressed and did not want the door closed. -Had a blanket that was with her to pull up over her. She had a call light but did not always use it. She stayed in bed as much as possible and had snacks in her room. It was all about the approach with her, smile and soft tones. She complained about being here, and it depended on how she felt whether she would cooperate with staff. She said herself she was racist and did not like the staff of color. So they always tried to have a white staff person available when care was given to her. Review of resident 50's 6/26/19 care plan revealed: Problem/Strengths: She had signs and symptoms of depression. Interventions: -Administer medications. -Monitor for signs of depression. -Involve in activities daily. -Notify MD immediately of suicidal ideation, self harming. -Social services to encourage resident to verbalize feelings, provide validation, and provide reassurance as needed. -Social services and activities: In room visits for social stimulation if resident could not attend activities. -Psych (psychiatric) consult as indicated. The care plan had been updated and did address: -The refusal for mental health services. -That group activities were not an option. -What warranted the as needed visits by the social worker (SW). -That she would not wear clothes when she was lying in bed, and did not pull her privacy curtain or close her door. -What activity staff should do during the one-to-one visits. -What upset her? -That she self acknowledged she was racist, and certain caregivers might upset her. Interview on 10/16/19 at 3:00 p.m. with Minimum Data Set (MDS) assessment coordinator [NAME] regarding resident 50 revealed: She was unaware the resident sat with no clothes on when she was in her room. She confirmed the care plan had not been updated since admission and was not individualized for her. She was aware their care plans were not individualized. She did not work on the floor: -So she relied on the appropriate department to update their care plan She relied on the floor staff to inform her of changes with residents. 2. Observation on 10/15/19 at 2:48 p.m. of resident 11 revealed: He had been: -Laying in his bed sleeping. -Positioned on his left side and was facing the wall. His bed had: -Been pushed up against the wall on the left side. -Been in the low position and was close to the floor. -A floor mat positioned on the floor next to the bed. There had been a wedged cushion placed underneath of his mattress on the right side of his bed. That wedged cushion had: -Been positioned in the middle of the bed. -Created a large raised area behind the resident's lower back and bottom. Review of resident 11's undated pocket care plan information revealed: His bed was to have been in the low position and a floor mat next to the bed. A foam noodle was to have been placed underneath the mattress. Observation on 10/15/19 at 4:57 p.m. of resident 11 revealed he continued to lay in bed as observed above and had not made any noticeable change in his position. Interview on 10/15/19 at 5:13 p.m. with certified nursing assistants (CNA) M and P regarding the wedged pillow revealed: They confirmed the resident had a history of [REDACTED]. The wedged cushion was used to keep the resident from falling out of his bed. CNA P stated: -That's a restraint isn't it? -We put it in there (wedged cushion) to stop him from getting out of his bed. -If we don't he'll be right on the floor. They used the pocket care plans to ensure the proper care was provided for the residents. They were unsure how they were updated or who updated them. Review of resident 11's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED]. He was dependent upon the staff to assist him with all activities of daily living (ADL) and anticipate his needs. There was no documentation to support why he had required the use of a wedged pillow or foam noodle underneath of his mattress when laying in his bed. Review of resident 11's comprehensive care plan revealed: Multiple initiated and reviewed dates for focus areas and interventions. He had a focus area supporting he was at risk for falls and was initiated on 8/31/17. The interventions for that focus area had been: -Hi/low bed will be in lowest position. -Scoop mattress on bed. -Fall mat on floor next to bed when resident in bed. -No intervention to support the use of a wedged cushion or foam noodle underneath of his mattress. No documentation that he required the use of a Pummel cushion when sitting in his wheelchair. Interview on 10/16/19 at 4:50 p.m. with the MDS assessment coordinator T revealed she: Confirmed: -The above observations and concerns identified for resident 11. -The staff used the pocket care plan to ensure the resident received the proper care and services he had required. To her knowledge the pocket care plan had been considered a part of their comprehensive care plan. -She: --Was not sure who updated them and how. --Stated: I know they are discussed every morning in our standup meeting. Would have expected the care plan to support their current care and services they had required. Stated: -We all are (interdisciplinary care team) responsible for the updating of the care plan. -I only review them and update them when I do the resident's assessment. Would not have: -Made sure the care plan was accurate and up-to-date. -Assessed the residents and been proactive with determining their care needs. All her information for the residents had been data driven. -Attended care conferences to assist the interdisciplinary care team with reviewing the care plans on the residents and with their representatives. -Attended care conferences to ensure the care plan was accurate and true to support care for the residents had occurred. Stated: I only came back to help them with the MDS assessments, and here I am still here after all this time. Interview on 10/17/19 at 11:23 a.m. with the DON and the administrator regarding resident 11 revealed they: Confirmed the resident had a history of [REDACTED]. The pocket care plan was not considered a part of his care plan. -It was a quick resource for the staff to use. -All of the management team was responsible for updating them. -That information should have been found on his comprehensive care plan. Were not aware the staff had been placing the wedged cushion underneath his mattress. -That cushion was to have been placed directly behind his back. Would have expected the care plan to have been updated to reflect the current care and services he required. 3. Observation and interview on 10/16/19 at 4:20 p.m. with RN R in resident 235's room revealed: He had been laying on the bed. -The Prevalon boot was on the floor. -He had a shoe on his left foot. -There was a shoe and sock on the bed next to his right foot. -The right foot had not been off-loaded off of the bed. RN R: -Removed a dressing to the resident's right foot bunion area. -There was a small opened area to the right side of the great toe on the bony prominence. --The area was opened. There was a white message board on the wall next to the bathroom stating: -Family is concerned about draining sore on right bunion. ? cultures needed. Interview at the above time with RN R regarding resident 235 revealed: He had a stage two pressure ulcer to his left heel that started out as a water filled blister. The certified nurse practitioner had seen the resident that day and had written an order for [REDACTED]. Review of resident 235's medical record revealed: An admission date of [DATE]. [DIAGNOSES REDACTED]. There was no baseline care plan. Review of the 9/25/19 admission MDS assessment for resident 235 revealed: He was at risk for developing pressure ulcers or injuries. He had one stage two pressure ulcer. He was coded as having: -A pressure device for the chair and bed. -Pressure ulcer/injury care. The Care Area Assessment Summary was coded for pressure ulcer area triggered and care planning decision. Review of the Braden Scale for Predicting Pressure Sore Risk from 9/18/19 through 10/8/19 for resident 235 revealed: A score of fifteen. A score of twelve or less represented a high risk. Review of the following physician's orders [REDACTED]. 9/18/19: -Complete weekly skin assessment. 10/8/19: -Saline to clean area to right great toe daily and with soilage and covering with dry dressing until healed. 10/14/19: -The nurse informed the physician per fax that the area to his great right toe measured 0.5 centimeters (cm) by 1.0 cm. --Physician's response was will see on rounds. 10/16/19: -Send pt (resident) wound care clinic for treatment right foot wound. -Pt to wear Rook (Prevalon) boot at all times to prevent further breakdown of heel wound on left foot. Review of the 9/18/19 Weekly Pressure Ulcer Record for resident 235 revealed: The body diagram to identify sites for non-pressure skin condition dated 9/18/19 had a circle drawn around the anterior right foot. -There was no documentation to explain what that circled area meant. Review of the nursing progress notes from 10/7/19 through 10/14/19 for resident 235 revealed on: 10/7/19: -Reported to writer this AM that family member of resident noted an area to right great toe, when touched the area began draining. Upon writer assessment, yellow drainage coming from side of right great toe, small amount, no odor. PCP (primary care provider) aware and will be out to facility to assess on 10/8/19. 10/14/19: -Resident has an area 0.5 x 1 cm on right great toe that has eschar present. Surrounding area is reddened. This is on bony prominence of bunion. Await PCP order as she was notified per fax. Review of the 9/18/19 through 10/5/19 skin assessment documentation for resident 235 revealed on: 9/18/19: There was no documentation regarding the right great toe foot wound. 9/24/19: There was no documentation regarding the right great toe foot wound. 10/5/19: He has a small red, swollen area on the side of right foot. Review of the 10/8/19 physician's progress note for resident 235 revealed: Has stage one [MEDICAL CONDITION] on lateral right great toe. [MEDICAL CONDITION] associated with diabetes mellitus due to underlying condition. -Will use saline to wound every day and with spoilage dressed with 4 x 4. -Daily dressing change and as needed. Lateral right great toe with stage one ulcer, no exudate. Review of the current care plan with the following date listed for problems/strengths for resident 235 revealed: 10/10/19: -Problem: Resident has stage 2 pressure ulcer on left heel. -Refer to weekly pressure ulcer sheet for weekly measurements and staging. There was no documentation regarding the right foot diabetic ulcer. Interview on 10/17/19 at 4:15 p.m. with the DON regarding resident 235's right foot diabetic ulcer revealed: They should have done more with assessing it. Their usual routine for pressure ulcers was to measure the area, notify the physician, and do risk management. There should have been further documentation for the right foot diabetic ulcer. She would have expected the body diagram to identify sites for non-pressure skin condition dated 9/18/19 to have further documentation than just a circle drawn around the anterior right foot. The care plan should have been updated to reflect his right foot diabetic ulcer. Surveyor: 4. Review of the provider's 4/3/18 Care Plans - Comprehensive policy revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. *The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans.	2020-09-01
186	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	658	G	1	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure that professional standards were followed for: One of one closed sampled resident (380) who had been identified with a significant change in condition. One of one sampled resident (38) who had ongoing assessment and treatment for [REDACTED]. Findings include: 1. Review of the medical record for resident 380 revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status (BIMS) assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: An effective date of 7/25/19. Problems/Strengths: At risk for falls related to balance problems during transfers. Goals: -No falls. -Will be free from injury related to fall. Interventions: -Will receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach, with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose and a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider was asked to see him while in the building on rounds. -An order was received from his primary care provider to send him to (hospital name) emergency department for evaluation. -The non-emergency number was contacted, and resident left the faciity on a stretcher. Review of the 9/22/19 fall report for resident 380 revealed: It had occurred at 7:00 a.m. on 9/22/19. He was unable to give an explanation of the event that had occurred and was unresponsive. He had a history of [REDACTED]. The area of the form for physician signature of notification had been left blank. Review of the 9/22/19 Neuro (neurological) flow sheet for resident 380 revealed: The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then every hour for four hours, then every eight hours for a total of twenty-four hours. -Areas to be evaluated included level of consciousness (L[NAME]), pupil response to light, hand grip strength, vital signs, and response to verbal directions. On 9/22/19 at 7:00 a.m.: -He was alert. -His pupil response was not verified due to his eyes being shut. -The grip strength on his right hand was weak, and his left hand was strong. -The vital signs included: blood pressure (B/P) 139/68, temperature (T) 98.5 degrees, pulse (P) 78, and respirations (R) 18. -He was not responding to verbal directions. On 9/22/19 at 7:30 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 135/72, T 96.9, P 68, and R 20. -He was not responding to verbal directions. On 9/22/19 at 8:00 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included:B/P 148/79, T 95.4, P 79; and R 24. -He was not responding to verbal directions. On 9/22/19 at 8:30 a.m.: -He was alert. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 158/86; T 95.8; P 88; and R 22. -No response was listed with the following of verbal directions. On 9/22/19 at 10:00 a.m.: -He was unresponsive. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 199/85, T 97.0, P 63, and R 22. -No response was listed for following verbal directions. -The PCP was present. All flow sheet entries had been completed by LPN K. Review of the 9/22/19 physician's order sheet for resident 380 revealed: 9/22/19 - Head Injury with poor responsiveness- Recommend evaluate in (hospital name). It was signed by the resident's PCP. It was noted by LPN K and dated 9/22/19. There was no time listed by physician or LPN K signatures. Interview on 10/15/19 at 2:36 p.m. with certified nursing assistant/certified medication assistant (CNA/CMA) L regarding resident 380 on 9/22/19 revealed: Her shift began at 6:00 a.m. on the above date. He was sitting by the nurses' station when she had arrived that morning. He had a history of [REDACTED]. She was assisting another resident when CNA M called for assistance. He was laying on the floor near his roommate's bed and was face down. There was blood that appeared to be coming from his nose, and his dentures had fallen out. He was transferred with the mechanical lift from the floor to his bed to be assessed and then into his wheelchair. He was taken to the dining room to eat. -He would not eat any food. -When he attempted to drink it would fall out of his mouth. He was not swallowing. He was brought back to the nurses' station following the attempt to eat breakfast. She observed the staff being unable to reach the resident's spouse by telephone. Interview on 10/15/19 at 2:48 p.m. with CNA M regarding resident 380 on 9/22/19 revealed: She heard LPN K calling out for assistance. She obtained the vital sign machine and mechanical lift as instructed by LPN K. He was observed laying on the floor with some bleeding, and his dentures falling out. Vital signs were obtained while he was laying on the floor. She stayed with the resident while LPN K telephoned the on-call medical provider. The nurse returned and instructed them to move him to his bed. He was then transferred to his wheelchair to sit at the nurses' station since staff were always present. He was not talking, and she described him as groggy and zombie-like. -His baseline was to be verbally responsive and talkative. She acknowledged she felt something was going on with his health. Interview on 10/15/19 at 3:02 p.m. and again at 3:56 p.m. with the director of nursing (DON) regarding the events on 9/22/19 revealed: There were to be two CNAs and a medication aide scheduled that day, but the medication aide had called in. The census was approximately thirty residents in that part of the building. She acknowledged the fall report stated he was unresponsive at 7:00 a.m. but clarified he was only in that state upon initial observation. Interview by telephone on 10/15/19 at 3:38 p.m. with resident 380's primary care provider regarding the events of 9/22/19 revealed: He had arrived later than his normal time frame to make rounds on residents but did not give a time-frame. He was in the building doing rounds on other residents when staff alerted him resident 380 needed to be assessed. Verbalized it was approximately 10:30 a.m. to 11:00 a.m. when he saw the resident. Had observed him in the wheelchair rocking and slightly incoherent. The information shared with him by the nursing staff indicated: -They had telephoned the on-call provider immediately following the fall. -The on-call provider did not feel he had been significantly injured from the fall. He was surprised the staff had not called the on-call provider back regarding his change in condition. -He felt they might not have done that since they knew he would be in the facility for rounds. He thought the resident was likely experiencing a stroke or a bleed when he was assessed. It would be his expectation the resident should have been transferred to the emergency department (ED) for evaluation for his acute change in condition. There was no written progress note of his assessment of that resident. Interview by telephone on 10/15/19 at 3:44 p.m. with registered nurse (RN) N regarding resident 380 on 9/22/19 revealed: She had worked the overnight shift on another unit but was still in the building. She was asked to assist for a fall that she was told looks weird. Her observation indicated: -There was no facial droop, but something seemed off. -His hand grip strength was weak on both sides. -He was responding slower than his normal, and his speech was garbled. -One arm appeared to be flinching or cringing, and she was not sure if he was in pain. She had told LPN K, He's not right. His baseline was he would not always answer questions appropriately but would respond. LPN K addressed her feedback with, I am assessing him and I'll take care of it. In her nursing judgement of that day she stated she would have sent him in to be evaluated right away. Interview on 10/15/19 at 4:20 p.m. and again on 10/16/19 at 8:25 a.m with the administrator regarding resident 380 on 9/22/19 revealed: She was the supervisor on-call when the incident had occurred. LPN K had stated he was found on the floor, would not eat, and was fussy and resistive. -Encouraged her to visit with the physician but that had already been done. She acknowledged the preferred hospital was not listed on the resident's face sheet and should have been. It was her expectation a resident experiencing a drastic change in condition should have been transferred to the ED for evaluation. There was no professional standard in place at the time that event had occurred. -They would be using Lippincott with their new process. Interview on 10/16/19 at 9:46 a.m. with LPN K regarding resident 380 on 9/22/19 revealed: He had been dressed for the day and was sitting in his wheelchair at the nurses station when she arrived to work at 6:00 a.m. -He would frequently propel himself in the wheelchair around the facility. -She had encouraged him to stay at the nurses' station, but he chose to go back to his room. She entered his room to complete a blood sugar check around 7:00 to 7:15 a.m. He was laying on the floor and was slightly on his right side. -His nose was bleeding, and he was fumbling with his dentures that had fallen out. She summoned the assistance of several other staff to assist. She placed a call to the on-call physician. -The vital signs and range of motion had been completed but neurological checks had not been completed. -The physician asked if he was comfortable or in any pain. She felt he was not in any pain. -He requested the resident be moved from the floor and receive a full assessment. If there was any concerns he was to be called back. -Acknowledged she had not told the provider she thought he should be transferred to the hospital for evaluation. He was moved from the floor to his bed for a complete assessment. -Neuro checks were completed. Attempted to use the pen light to his eyes, but he had them shut tight. The second set of vitals completed at 7:30 a.m. were acceptable, but he was not following commands. -Verbalized that was not abnormal, as he was sometimes stubborn. She made the decision to bring him out to the nurses' station. -She was the only nurse assigned to that unit. -She wanted to be able to observe him. Staff had decided to take him to the dining room. -He was unable to eat or drink. -She felt that action might have accounted for the gap between 8:30 a.m. to 10:00 a.m. with his vital signs and neuro assessments. She felt the resident had a change in condition and needed to be transferred around 9:00 to 9:30 a.m. -She was not able to locate his preferred hospital in the medical record. -She telephoned the facility administrator and nurse back. -She was not able to reach the resident's spouse by telephone following the event. She was not sure when the resident's provider had arrived but thought it was after 9:00 a.m. -He had ordered the resident to be transferred to the emergency department for evaluation. She acknowledged her actions were done using her own nursing judgment and not based on a facility policy or procedure. -The policy and procedures had been given to her upon being hired, but she was not sure where they were currently located. She could not recall completing any recent skill competencies. Acknowledged he had been sent to the emergency department by non-emergent transfer. -Was not able to give a rationale for a non-emergent transfer and stated, It just happened that way. Review of the 9/22/19 to 9/24/19 hospital medical record for resident 380 revealed: He arrived at the emergency department at 11:21 a.m. A physician's note on 9/22/19 at 2:31 p.m. indicated: -Patient (resident) is a level I stroke code upon arrival .Initial last normal time is not clear however this was verified to be at 6:30 a.m., and unfortunately he is past the TPA (tissue plasminogen activator -a protein used to breakdown blood clots) window. -We did call the nursing home to verify last known well. At 6:30 a.m. he was able to get up in his chair and was acting normal per the nurse. It is not clear why there was a delay before he was brought to the ED. -On arrival the patient is not moving his left side he does have complete [MEDICAL CONDITION] and is nonverbal and looking to the right. His [DIAGNOSES REDACTED]. A physician's note on 9/24/19 at 12:36 p.m. indicated: -R MCA (right middle cerebral artery) stroke with large volume hemorrhage within the stroke zone, with the development of uncal herniation. Per discussion with the patient's family, decision made to transition to Comfort/Hospice. He passed away in hospice care on 9/24/19. Review of the provider's (MONTH) 2013 Job Description for Charge Nurse (RN or LPN) revealed: Monitors and documents changes in health status through continuing assessment of the resident. Observes, records and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. Knows and is is able to carry out approved emergency procedures. Review of the provider's 4/3/18 Change in a Resident's Condition or Status policy revealed: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition A 'significant change' of condition is a decline or improvement in the resident's status that .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of the provider's 8/15/19 Neurological Assessment policy revealed, Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately. Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis., (YEAR), p. 176, revealed: It is important to recognize early indicators of acute illness in older adults .A key principle of providing age-appropriate nursing care is timely detection of these cardinal signs of illness so early treatment can begin. 2. Review of resident 38's medical record revealed:She had been admitted on [DATE]. She had a BIMS score of ninety-nine indicating she was unable to complete the interview. Her [DIAGNOSES REDACTED].>-Unspecified dementia with behavioral disturbance. -Localized [MEDICAL CONDITION]. -Unspecified [MEDICAL CONDITION], unspecified site. -Unspecified sensorineural hearing loss. -Constipation. -[MEDICAL CONDITION]. -History of falling. Interview and observation on 10/15/19 at 2:56 p.m. with CNAs D and J regarding resident 38 revealed: She required two staff assist to transfer into the bed. She had two pink colored bandages to the outside of her left leg below the knee. -They had a date of 10/7/19 written on them. She had been admitted from another long term care facility with a pressure ulcer to her right buttock which had been healed. The CNAs applied [MEDICATION NAME] ointment that was kept at her bedside to her buttocks when they changed her brief. The wounds on her leg had been there since she was admitted . Interview and observation on 10/15/19 at 3:23 p.m. with registered nurse (RN) I regarding resident 38 revealed: The wound on the left leg had been there prior to admission. She was not sure what kind of wound it was. She did not know when the dressing was changed. She had looked to see when the dressing was scheduled to be changed and what type of dressing was used. -She could not find an order. She then went into the resident's room and removed two pink foam type dressings that were about four inches by four inches. -That revealed two superficial opened areas about the size of a nickel with a scant amount of red drainage to the dressings. She then covered the wounds with two large bandaids dated 10/15/19. Review of resident 38's non-pressure skin condition reports dated 7/27/19 through 10/10/19 had not addressed the opened areas on her left leg. Review of resident 38's skin assessment notes dated 8/29/19 through 10/10/19 revealed there was no documentation of opened areas on her left leg. Review of resident 38's medication and treatment administration records for (MONTH) 2019 revealed: No documentation of opened areas on resident's left leg. No order for or documentation of [MEDICATION NAME] ointment to be applied to the resident. Interview on 10/17/19 at 11:00 a.m. and at 2:35 p.m. with RN I regarding resident 38 revealed: If she found a wound she would notify the doctor and get an order for [REDACTED].>She: -Would have documented on the skin assessment sheet along with measurements of the wound. -Agreed there was not an order for [REDACTED]. -Had thought another nurse had applied those bandages. -Agreed the wounds should have been looked at, and the dressings should have been changed regularly. -Agreed she should have notified the physician and asked for orders on 10/15/19. -Had not called the physician to notify him of the wound or ask for orders by 10/17/19 at 2:35 p.m. Review of the physician's orders in Point Click Care on 10/17/19 at 2:09 p.m. revealed: RN I had entered a written physician's order at 11:06 a.m. that read: Resident has two small superficial wounds to Left leg. Need to change bandages one time a day for wounds related to [MEDICAL CONDITION], UNSPECIFIED (I73.9). No order for [MEDICATION NAME] Ointment. Interview on 10/17/19 at 4:15 p.m. with the DON regarding resident 38 revealed: She would have expected if a nurse had found an opened wound the nurse would have: -Measured the area upon finding it and then weekly until it was healed. -Notified the physician. -Entered a risk management note. -Asked the physician for dressing change orders if needed. The nurses used fax communications when communicating with a physician. -Those communications were kept in a basket at the nurses station until they were answered. -If not answered they would fax them again the next day. Nurses kept a communication book at the nurses station to communicate residents with wounds. The policy was to call a physician and get an order for [REDACTED].>[MEDICATION NAME] needed to be ordered by a physician. [MEDICATION NAME] ointment was a medication and should have been kept in the medication cart and administered by the nurse. Review of resident 38's 6/20/19 care plan revealed: She was at risk for developing pressure ulcers related to impaired mobility and incontinence. She would not develop pressure ulcers. Keep skin clean, dry. Monitor skin integrity while providing care and every week by licensed nurse. Turn and reposition every two hours. Pressure reducing mattress. Pressure relieving device when in chair: cushion It did not address the opened areas on left leg. Review of the provider's undated Wound Care policy revealed: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. *It indicated to document in the medical record when wound care was given along with the assessment of the wound and the type of wound care given.	2020-09-01
187	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	679	D	0	1	SJ6G11	Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (50) who was socially isolated received an individualized activity program based on her interests and needs. Findings include: 1. Interviews and observations on 10/15/19 at 3:00 p.m. and on 10/16/19 at 9:45 a.m. of resident 50 revealed she: Was alert and oriented to person and place. Stated loudly, This place sucks and went on to say how unhappy she was there. -Felt like she was just put there to die, and all the staff cared about was getting her money. -Did not go to any activities and emphatically did not care to go. -Had a computer that she thought she should bring into her room but did not know where it was. -Went to the dining room for breakfast and lunch, but not supper. --Had not visited with any peers and was unhappy with the other residents in the dining room. Review of resident 50's 6/24/19 initial Minimum Data Set (MDS) assessment revealed she: Was cognitively intact. Felt down and depressed. Was tired and had little energy. Had important preferences for the following activities: -Having things to read. -Music. -Animals. -Religion. Going to group activities was not at all important. Review of resident 50's 6/26/19 care plan revealed: Problem/Strengths: She had signs and symptoms of depression. Interventions: -Monitor for signs of depression. -Involve in activities daily. -Social services and activities: in room visits for social stimulation if resident could not attend activities. Interview on 10/17/19 at 7:20 a.m. with activity assistant H regarding resident 50 revealed: She was new to her position having only been there three weeks. -The activity director was gone for ten days. The resident had not come to any activities. -If you tried to encourage her she had a melt down and started crying saying its too much. They did one-to-one (1:1) activities with her mainly by just stopping into visit with her. -She tried to visit at least five minutes, but then she became paranoid about why you were talking to her. She watched TLC on TV. She came out to meals but was never seen conversing with anyone. She could get angry real easy. She did not care for you to be there and got angry if you asked questions. She was unaware the resident had a computer or where it was at. -She had not heard about that before. Review of resident 50's (MONTH) and (MONTH) 2019 activity participation records revealed: There was no documentation she had been invited to and refused daily group activities. There was documentation of 1:1s, but it did not reflect what was done during those 1:1's. There was no documentation she had been offered reading materials, music, or spiritual programs. She had only participated in a pet program once, and that was the day she had been admitted . Review of the provider's 4/3/18 Activity Assessment policy revealed: The activity assessment is used to develop an individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/he choice and interest. Each resident's activities care plan shall relate to his/her comprehensive assessment and should reflect his/her individual's needs. Review of the provider's 3/24/17 Activity Program policy revealed: Out activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. *Out activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident.	2020-09-01
188	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	684	G	1	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, job description review, interview, and policy review, the provider failed to ensure one of one closed sampled resident (380) received appropriate care and services following an unwitnessed fall. Findings include: 1. Review of resident 380's closed medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the information face sheet for resident 380 revealed the preferred hospital line had been left blank. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: An effective date of 7/25/19. Problems/Strengths: At risk for falls related to balance problems during transfers. Goals: -No falls. -Will be free from injury related to fall. Interventions: -Will receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach, with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and there was a skin tear on his left elbow. -Resident was partially assessed by the nurse while he was on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was then transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider (PCP) was asked to see him while in the building on rounds. -An order was received from his PCP to send him to (hospital name) emergency department (ED) for evaluation. -The non-emergency number was contacted, and the resident left the faciity on a stretcher. Review of the 9/22/19 fall report for resident 380 revealed: It had occurred at 7:00 a.m. on 9/22/19. He was unable to give an explanation of the event that had occurred and was unresponsive. He had a history of [REDACTED]. The area of the form for physician signature of notification had been left blank. Review of the 9/22/19 Neuro (neurological) flow sheet for resident 380 revealed: The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or an unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then every hour for four hours, then every eight hours for a total of twenty-four hours. -Areas to be evaluated included level of consciousness (L[NAME]), pupil response to light, hand grip strength, vital signs, and response to verbal directions. On 9/22/19 at 7:00 a.m.: -He was alert. -His pupil response was not verified due to his eyes being shut. -The grip strength on his right hand was weak, and his left hand was strong. -The vital signs included: blood pressure (B/P) 139/68, temperature (T) 98.5 degrees, pulse (P) 78, and respirations (R) 18. -He was not responding to verbal directions. On 9/22/19 at 7:30 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 135/72, T 96.9, P 68, and R 20. -He was not responding to verbal directions. On 9/22/19 at 8:00 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 148/79, T 95.4, P 79; and R 24. -He was not responding to verbal directions. On 9/22/19 at 8:30 a.m.:-He was alert. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 158/86; T 95.8; P 88; and R 22. -No response was listed with the following of verbal directions. On 9/22/19 at 10:00 a.m.: -He was unresponsive. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 199/85, T 97.0, P 63, and R 22. -No response was listed with the following of verbal directions. -The PCP was present. All flow sheet entries had been completed by LPN K. Review of the physician's orders [REDACTED]. 9/22/19 - Head Injury with poor responsiveness- Recommend evaluate in (hospital name) ED. It was signed by the physician. It was noted by LPN K and dated 9/22/19. There was no time listed by the physician or LPN K signatures. Interview on 10/15/19 at 2:36 p.m. with certified nursing assistant/certified medication assistant (CNA/CMA) L regarding resident 380 on 9/22/19 revealed: Her shift began at 6:00 a.m. on the date of the fall. He was sitting by the nurses' station when she had arrived that morning. He had a history of [REDACTED]. She was assisting another resident when CNA M called for assistance. He was laying on the floor near his roommate's bed and was face down. Blood appeared to be coming from his nose, and his dentures had fallen out. He was transferred with the mechanical lift from the floor to his bed to be assessed and then into his wheelchair. He was taken to the dining room to eat. -He would not eat any food. -When he attempted to drink it would fall out of his mouth. He was not swallowing. He was brought back to the nurses' station following the attempt to eat breakfast. She observed LPN K being unable to reach the resident's spouse by telephone. Interview on 10/15/19 at 2:48 p.m. with CNA M regarding resident 380 on 9/22/19 revealed: She heard LPN K call out for assistance. She obtained the vital sign machine and mechanical lift as instructed by LPN K. He was observed laying on the floor with some bleeding, and his dentures had fallen out. Vital signs were obtained while he was laying on the floor. She stayed with the resident while LPN K telephoned the on-call physician. The nurse returned and instructed them to move him to his bed. He was then transferred to his wheelchair to sit at the nurses' station since staff were always present. He was not talking, and she described him as groggy and zombie-like. -His baseline was to be verbally responsive and talkative. She acknowledged she felt something was going on with his health. Interview on 10/15/19 at 3:02 p.m. and again at 3:56 p.m. with the director of nursing regarding the events on 9/22/19 revealed: There were to be two CNAs and a medication aide scheduled that day, but the medication aide had called in. The census was approximately thirty residents in that part of the building. She acknowledged the fall report stated he was unresponsive at 7:00 a.m. but clarified he was only in that state upon initial observation. Verbalized the medical records department was responsible for placing the preferred hospital on the information face sheet. Interview by telephone on 10/15/19 at 3:38 p.m. with resident 380's primary care physician regarding the events of 9/22/19 revealed: He had arrived later than his normal time frame to see residents but did not give a time frame. He was in the building seeing other residents when staff alerted him that the resident needed to be assessed. Verbalized it was approximately 10:30 a.m. to 11:00 a.m. when he saw the resident. Observed him in the wheelchair rocking back and forth and slightly incoherent. The information shared with him by the nursing staff indicated: -They had telephoned the on-call physician immediately following the fall. -The on-call physician did not feel he had been significantly injured from the fall. He was surprised the staff had not called the on-call physician back regarding his change in condition. -He felt they might not have done that since they knew he would be in the facility for rounds. He thought the resident was likely experiencing a stroke or a bleed when he was assessed. It would be his expectation the resident should have been transferred to the emergency department for evaluation for the acute change in condition. There was no written progress note of his assessment of the resident. Interview by telephone on 10/15/19 at 3:44 p.m. with registered nurse (RN) N regarding resident 380 on 9/22/19 revealed: She had worked the overnight shift on another unit but was still in the building. She was asked to assist for a fall she was told looks weird. Her observation indicated: -There was no facial droop, but something seemed off. -His hand grip strength was weak on both sides. -He was responding slower than his normal, and his speech was garbled. -One arm appeared to be flinching or cringing, and she was not sure if he was in pain. She told LPN K, He's not right. His baseline was he would not always answer questions appropriately but would respond. LPN K addressed her feedback with, I am assessing him, and I'll take care of it. In her nursing judgement of that day she stated she would have sent him in to be evaluated right away. Interview on 10/15/19 at 4:10 p.m. with the director of medical records regarding the information face sheet for resident 380 revealed: She would enter the preferred hospital in the appropriate field if it was known. The process at the time of the resident's admission involved the social worker forwarding that information to her. Interview on 10/15/19 at 4:15 p.m. with social worker W regarding the information sheet for resident 380 revealed: He initially verbalized it was a duty of the medical records department. -He was provided information regarding the above interview with medical records. He described the absence of a preferred hospital on the form as a data-entry error, and there was no good reason why it had occurred. The process in place at the time of the resident's admission and the above event indicated: -He would collect and send out the resident's information to the appropriate departments approximately two days prior to admission. -It had been his responsibility, but there was no policy and procedure in place. Interview on 10/15/19 at 4:20 p.m. and again on 10/16/19 at 8:25 a.m. with the administrator regarding resident 380 on 9/22/19 revealed: She was the supervisor on-call when the incident had occurred. LPN K had stated he was found on the floor, would not eat, and was fussy and resistive. -Encouraged her to visit with the physician, but that had already been done. She acknowledged the preferred hospital should have been on the information sheet. It was her expectation a resident experiencing a drastic change in condition should have been transferred to ED for evaluation. There was no professional standard in place at the time that event occurred. -They would be using Lippincott with their new process. Interview on 10/16/19 at 9:46 a.m. with LPN K regarding resident 380 on 9/22/19 revealed: He had been dressed for the day and was sitting in his wheelchair at the nurses station when she arrived to work at 6:00 a.m. -He would frequently propel himself in the wheelchair around the facility. -She encouraged him to stay at the nurses' station, but had chosen to go back to his room. She entered his room to complete a blood sugar check around 7:00 a.m. to 7:15 a.m. He was laying on the floor and was slightly on his right side. -His nose was bleeding, and he was fumbling with his dentures that had fallen out. She summoned the assistance of several other staff to assist. She placed a call to the on-call physician. -The vital signs and range of motion had been completed, but neurological checks had not been completed. -The physician had asked if he was comfortable or in any pain. She felt he was not in any pain. -He requested the resident be moved from the floor and receive a full assessment. If there was any concerns he was to be called back. -Acknowledged she did not tell the provider that she thought he should be transferred to the hospital for evaluation. He was moved from the floor to his bed for a complete assessment. -Neuro checks were completed. Attempted to use the pen light to his eyes, but he had them shut tight. The second set of vitals completed at 7:30 a.m. were acceptable, but he was not following commands. -Verbalized that was not abnormal as he was sometimes stubborn. She made the decision to bring him out to the nurses' station. -She was the only nurse assigned to that unit. -She wanted to be able to observe him. Staff had decided to take him to the dining room. -He was unable to eat or drink. -She felt that action might have accounted for the gap between 8:30 a.m. to 10:00 a.m. with his vital signs and neuro assessments. She felt the resident had a change in condition and needed to be transferred around 9:00 a.m. to 9:30 a.m. -Was not able to locate his preferred hospital in the medical record. -Telephoned the facility administrator and nurse back. -Was not able to reach the resident's spouse by telephone following the event. She was not sure when the resident's provider had arrived but felt it was after 9:00 a.m. -He had ordered the resident to be transferred to the emergency department for evaluation. She acknowledged her actions were done using her own nursing judgment and not based on a facility policy or procedure. -The policy and procedures had been given to her upon being hired, but she was not sure where they were currently located. She could not recall completing any recent skill competencies. Acknowledged he had been sent to the emergency department by non-emergent transfer. -Was not able to give a rationale for a non-emergent transfer and stated, It just happened that way. Review of the hospital medical record for resident 380 revealed: He arrived at the emergency department at 11:21 a.m. A physician's note on 9/22/19 at 2:31 p.m. indicated: -Patient (resident) is a level I stroke code upon arrival .Initial last normal time is not clear however this was verified to be at 6:30 a.m., and unfortunately he is past the TPA (tissue plasminogen activator -a protein used to breakdown blood clots) window. -We did call the nursing home to verify last known well. At 6:30 a.m. he was able to get up in his chair and was acting normal per the nurse. It is not clear why there was a delay before he was brought to the ED. -On arrival the patient is not moving his left side he does have complete [MEDICAL CONDITION] and is nonverbal and looking to the right. His [DIAGNOSES REDACTED]. A physician's note on 9/24/19 at 12:36 p.m. indicated: -R MCA (right middle cerebral artery) stroke with large volume hemorrhage within the stroke zone, with the development of uncal herniation. Per discussion with the patient's family, decision made to transition to Comfort/Hospice. He passed away in hospice care on 9/24/19. Review of the (MONTH) 2013 Job Description for Charge Nurse (RN or LPN) revealed: Monitors and documents changes in health status through continuing assessment of the resident. Observes, records and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. Knows and is is able to carry out approved emergency procedures. Review of the 4/3/18 Change in a Resident's Condition or Status policy revealed: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition *A 'significant change' of condition is a decline or improvement in the resident's status that .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of the 8/15/19 Neurological Assessment policy revealed, Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.	2020-09-01
189	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	686	G	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (74 and 235) who were at risk for developing pressure ulcers had ongoing assessments and implemented individualized interventions in place to prevent skin breakdown. Findings include: 1. Review of resident 235's medical record revealed: An admission date of [DATE]. [DIAGNOSES REDACTED]. He had orders for a diabetic renal diet. Review of the 9/25/19 admission Minimum Data Set (MDS) assessment for resident 235 revealed: He was able to understand what others said and make himself understood. The Brief Interview for Mental Status assessment score was thirteen indicating he was cognitive. He required: -Extensive assistance of one staff person for dressing and toilet use. -Limited assistance of one staff person for bed mobility, transfer, ambulation, and personal hygiene. He had limited range of motion to his lower extremity. He used a walker or wheelchair. Nutritional approaches had not been coded indicating he required a therapeutic diet. He was at risk for developing pressure ulcers or injuries. He had one stage two pressure ulcer. He was coded as having: -A pressure device for the chair and bed. -Pressure ulcer/injury care. The Care Area Assessment Summary was coded for pressure ulcer area triggered and care planning decision. Review of the Braden Scale for Predicting Pressure Sore Risk from 9/18/19 through 10/8/19 for resident 235 revealed a score of fifteen. -A score of twelve or less represented a high risk. Observation and interview on 10/15/19 at 4:21 p.m. with resident 235 in his room revealed: He was in the facility, because he had broken his left leg a few weeks ago. He had been receiving physical therapy. He had been laying on the bed, had his shoes on both feet, and his heels were not off-loaded. There was a Prevalon boot laying on the floor. Observation on 10/15/19 at 6:00 p.m. in the[NAME]Wing dining room regarding resident 235 revealed: He had regular shoes on both feet and no socks on. He had not been wearing the Prevalon boot. His heels had not been off loaded. Observation and interview on 10/16/19 at 4:20 p.m. with registered nurse (RN) R in resident 235's room revealed: He had been laying on the bed. -The Prevalon boot was on the floor. -He had a shoe on his left foot. -There was a shoe and sock on the bed next to his right foot. -The right foot had not been off-loaded off the bed. RN R: -Removed a dressing to the resident's right foot bunion area. -There was a small opened area to the right side of the great toe on the bony prominence. --The area was opened. There was a white message board on the wall next to the bathroom. -A note on the message board stated: Family is concerned about draining sore on right bunion. ? cultures needed. Interview at the above time with RN R regarding resident 235 revealed: He had a stage two pressure ulcer to his left heel that had started out as a water filled blister. The certified nurse practitioner had seen the resident that day and had written an order for [REDACTED]. Review of the following physician's orders [REDACTED]. 9/18/19: -Complete weekly skin assessment. -Skin prep (preparation) to left heel blister daily, Prevalon boot to [MI] (left) heel. DAY SHIFT -House supplement per registered dietitian. 10/8/19: -Discontinue Prevalon boot to left heel twice a day. -Saline to clean area to right great toe daily and with soilage and covering with dry dressing until healed. 10/14/19: -The nurse informed the physician per fax that the area to his great right toe measured 0.5 centimeters (cm) by 1.0 cm. --Physician's response was, Will see on rounds. 10/16/19: -Send pt (resident) wound care clinic for treatment right foot wound. -Pt to wear Rook (Prevalon) boot at all times to prevent further breakdown of heel wound on left foot. Review of the 9/22/19 Weekly Pressure Ulcer Record for resident 235 revealed: The left heel pressure ulcer had occurred on 9/22/19. -They had not documented on that area weekly. The body diagram to identify sites for non-pressure skin condition dated 9/18/19 had a circle drawn around the anterior right foot. -There was no documentation to explain what the area had revealed. Review of the nursing progress notes from 10/7/19 through 10/14/19 for resident 235 revealed on: 10/7/19: -Reported to writer this AM that family member of resident noted an area to right great toe, when touched the area began draining. Upon writer assessment, yellow drainage coming from side of right great toe, small amount, no odor. PCP (primary care provider) aware and will be out to facility to assess on 10/8/19. 10/14/19: -Resident has an area 0.5 x 1 cm on right great toe that has eschar present. Surrounding area is reddened. This is on bony prominence of bunion. Await PCP order as she was notified per fax. Review of the 9/18/19 through 10/5/19 skin assessment documentation for resident 235 revealed on: 9/18/19: There was no documentation regarding the right great foot wound. 9/24/19: There was no documentation regarding the right great foot wound. 10/5/19: He has a small red, swollen area on the side of right foot. Review of the 9/24/19 registered dietitian (RD) progress note for resident 235 revealed: Resident has a blister to left foot measuring 3.5 x 4.0. -Resident's BMI (body mass index) is 23.8, which is slightly below recommended range for older adults of 25-30. -Resident reports weight loss of 5 pounds and attributes it to exercise and anorexia. -Nutrition care plan added. Review of the 10/8/19 physician's progress note for resident 235 revealed:Has stage one [MEDICAL CONDITION] on lateral right great toe. [MEDICAL CONDITION] associated with diabetes mellitus due to underlying condition. -Will use saline to wound every day and with spoilage dressed with 4 x 4. -Daily dressing change and as needed. Lateral right great toe with stage one ulcer, no exudate. Review of the current care plan with the following dates listed for problems/strengths for resident 235 revealed: 10/10/19: -Problem: Resident has stage 2 pressure ulcer on left heel. -There was no documentation regarding the right foot diabetic ulcer. -RD consult. -Refer to weekly pressure ulcer sheet for weekly measurements and staging. 9/24/19: -Problem: At risk for weight loss/dehydration due to leaves 50% + food uneaten at most meals related to anorexia. -Dietary supplements as needed. -Between meal snacks. -There was no documentation regarding what the RD was doing regarding nutrition for the stage two pressure ulcer on the left foot or the right foot diabetic ulcer. Interview on 10/17/19 at 4:15 p.m. with the director of nursing (DON) regarding resident 235's right foot diabetic ulcer revealed:They should have done more with assessing it. There usual routine for pressure ulcers was to measure the area, notify the physician, and do risk management. There should have been further documentation for the right foot diabetic ulcer. She would have expected the body diagram to identify sites for the non-pressure skin condition dated 9/18/19 to have further documentation than just a circle drawn around the anterior right foot. The care plan should have been updated to reflect his right foot diabetic ulcer. 2. Observation and interview on 10/15/19 at 1:34 p.m. of resident 74 revealed he: Had: -Been in his room sitting in a wheelchair (w/c) watching television (TV). -A urinary catheter collection bag hanging underneath the w/c. -Pressure relieving Una boots on both of his feet. Stated: -I'm getting ready to go see the doc, I have a lot of fluid. -Yes, I have wounds on my feet because of all the fluid. -They said they were blisters then just opened up. Interview on 10/15/19 at 3:28 p.m. with RN Q regarding resident 74 revealed she: Confirmed he a pressure injury on his left heel. Was not sure if he had: -Acquired the pressure injury during his stay and while receiving care at the facility. -Required a dressing change for that pressure injury. Had to look on the computer to check to confirm the dressing change. Stated: -He does have a dressing change on that heel tomorrow. -I'm not sure of the time. -I haven't had time to do it yet today. -I float to all areas and different shifts, so I'm just not quite sure of some things. Review of resident 74's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED]. He had: -Good memory recall and was capable of making his needs known. -Been dependent upon the staff to assist him with all activities of daily living (ADL). --That had included bed mobility, transfers, personal hygiene, and dressing. -Not been able to walk and required the use of a w/c to go from place-to-place in the facility. He was to be repositioned every two hours. -There was no documentation to support he required the use of positioning devices. On 7/30/19 he had acquired a stage 2 pressure injury to his left heel. -That injury measured 1.3 centimeters (cm) by (x) 2.0 cm and had a scant amount of exudate draining from it. The skin around that wound was intact and pink in color. The wound bed was pink. -He had acquired that injury twenty days after his admission to the facility. -The staff were directed to use pressure relieving heel boots on his feet. --That intervention had not been put into place until after the identification and assessment of the pressure injury. On 8/3/19 the documentation supported his pressure injury had worsened and increased in size. --That pressure injury measured 2.0 cm x 3.0 cm and continued to have a scant amount of exudate draining from it. The wound bed was now pale in color with the surrounding tissue boggy (soft) and white in color. --The nursing staff had documented the wound had worsened due to the bogginess of the surrounding tissue. The opened area had remained the same size. --That wound had worsened within four days from the initial identification of it. The physician and family had been informed of the wound. The nursing staff had sent a faxed request on 7/30/19 to the physician requesting a treatment for [REDACTED]. There was no documentation to support: -Preventative measures were put in place in a timely manner to ensure he had not acquired a pressure injury to his left heel. -He had been admitted with that pressure injury. Review of resident 74's Braden Scale for Predicting Pressure ulcers score from 7/10/19 through 9/26/19 revealed: On 7/10/19: he was admitted with a score of twenty indicating he was at low risk for skin breakdown. On 7/13/19: -His score was a sixteen indicating he was now at risk for skin breakdown. -That score had dropped four points within four days of his stay in the facility. On 7/20/19: -His score was a fifteen indicating he was still at risk for skin breakdown. -That score had dropped five points within ten days of his admission to the facility. On 7/27/19: his score was a fifteen indicating he remained at risk for skin breakdown. On 8/3/19, there was no score calculated for him. On 9/26/19: -His score was a thirteen indicating his level of risk for skin breakdown had increased. -That score had dropped seven points from when he was initially assessed and admitted to the facility on [DATE]. Review of resident 74's initial nursing assessment tool revealed: It had been completed on 7/18/19. -That had been eight days after his admission to the facility. His skin was: -Warm and dry to the touch. -Swollen with 2+ [MEDICAL CONDITION] observed to both of his lower extremities. Review of resident 74's following interdisciplinary progress notes revealed: On 7/10/19: he had been admitted to the facility with 2+ [MEDICAL CONDITION] to his left lower extremity. -That was the only skin concern identified and documented on. On 7/23/19: Minimum Data Set (MDS) assessment coordinator T had written a summary supporting his admission assessment of 7/17/19. She had documented: -He has no pressure related skin concerns. -He had a pressure reducing mattress on his bed and cushion in his w/c. On 7/30/19 the nursing staff had documented: -Resident complaining of bilateral heel pain. Upon assessment (R) (right) heel is red blanchable to entire heel. (L) (left) later heel has 1.3 x 2 cm [MEDICATION NAME] tissue with intact edges, draining scant amount of drainage. -Area was cleansed per facility protocol and [MEDICATION NAME] applied for protection. Heel boots applied. -Explained to resident that to relieve pressure from both heels, that heel boots need to warn (be worn) instead of shoes; voiced understanding. Appropriate paperwork completed. -Wife, (name), notifies via phone. Fax sent to PCP (personal care provider) requesting orders for daily dressings, awaiting response. On 10/7/19: MDS assessment coordinator T had written a summary supporting his quarterly assessment of 9/26/19. She had documented: -He had a stage II pressure ulcer with treatments. There was no documentation to support where that was located. -He wears heel boots at all times. -He had a pressure reducing mattress on his bed and cushion in his w/c. Review of resident 74's 7/17/19 admission MDS assessment revealed he: Was at risk for skin breakdown/injuries. Had pressure relieving devices for his bed and w/c. Had no repositioning program in place. Review of resident 74's 9/26/19 quarterly MDS assessment revealed he: Had the same documentation as reviewed above on his admission assessment. Had acquired a stage 2 pressure injury. Review of resident 74's undated pocket care plan revealed no documentation to support he: Was at risk for skin breakdown and required staff support to be repositioned every two hours. Required the use of pressure relieving devices to ensure no skin breakdown had occurred. Had a pressure injury to his left heel, and he required the use of heel boots to relieve pressure for them. Review of resident 74's comprehensive care plan revealed: It had different initiation and revision dates for all the focus areas developed for him. On 7/23/19: a focus area was initiated and identified him at risk for developing pressure ulcers related to requiring assistance with bed mobility, decreased mobility, and having bowel incontinence. -He currently has zero pressure ulcers. -Goals and interventions had been put in place to promote prevention and healing of wounds. -The staff were to have repositioned him every two hours, and he had a pressure relieving mattress. There had been no interventions put in place to support he required repositioning devices such as pillows and heel boots. There was a Plan of Care Comments sheet containing multiple lines attached to the care plan. -On 7/30/19: a handwritten note stated, (L) lateral heel ulcer was on the top line of that comments sheet. --No interventions were written for that left lateral heel ulcer to promote healing of it. Review of resident 74's 7/10/19 admission orders [REDACTED]. Review of resident 74's 7/1/19 through 7/10/19 treatment administration record (TAR) from the admitting facility revealed no documentation to support he had a left heel pressure injury that had required assessments and treatments. Observation on 10/16/19 at 10:39 a.m. with RN R with resident 74 revealed: The resident was in his room sitting in his w/c watching TV. He had the Una boots on both of his feet. RN R: -Had prepared to complete the dressing change to the resident's left heel pressure injury. -Removed the resident's Una boot and sock from his left foot. There had been no dressing on the resident's left heel/foot for protection. With those dirty gloves on RN R: -Touched and felt the wound prior to showing it to the surveyor. --The pressure injury was located on the lateral aspect of his left heel. --The wound was approximately 1.0 cm x .5 cm with a red base. -Opened a package of 4x4 gauze and moistened it with wound cleanser from a bottle. -Cleaned the wound with that 4x4 gauze. -Put the resident's foot back down to rest on the Una boot. --The pressure injury came into direct contact with the outside surface of that Una boot. RN R: -Removed his gloves and without sanitizing or washing his hands put on another pair of gloves. -Opened the package containing the Sorbact gel gauze, removed it from the package, and placed it on the resident's opened wound. -Opened another package and placed a protective dressing over it. -Removed his gloves and put the resident's sock and Una boot back on. Interview on 10/16/19 at 10:55 a.m. with RN R regarding the above observation with resident 74 revealed he: Stated: -He had a shower this morning, so that is why there was no dressing on his foot. -Yes, the staff should have told me the dressing was off or removed, so I could have replaced it soon. -I was disappointed there wasn't a dressing covering the wound. -I typically don't work down here, so I wasn't even sure what I was going to find, I didn't even know he had a dressing change until you asked about it. -I have no idea how he got the wound. Agreed: -The dressing change was completed in an unsanitary manner. -A treatment completed in an unsanitary manner would have created the potential for poor healing and infection to have occurred. Had not realized: -All the surfaces he touched would have been considered dirty until reviewed with him. -He had touched and assessed the resident's wound with dirty gloves. Interview on 10/16/19 at 4:50 p.m. with MDS assessment coordinator T regarding resident 74 revealed she: Confirmed the stage 2 pressure injury to his left heel, and he was at risk for skin breakdown. Was not sure how or when he had acquired that injury. Stated: -I'm sure he was not admitted with it, it was just crazy. -They were taking two admissions a day from (facility name) and before you know it we had ten admissions in one week. -Yes, the staff use the pocket care plans to help them with cares for the residents and yes, it's considered a part of the comprehensive care plan. Would not have: -Assisted with determining those residents who had been at risk for skin breakdown. -Assisted the staff with determining pressure relieving measures for the residents at risk for skin breakdown. -Updated the comprehensive care plans in-between their assessments. Was not: -Responsible for the overall completion of the comprehensive care plans and was unsure who was. -Sure who updated the pocket care plans and comprehensive care plans between resident assessments. Would not have: -Assessed the residents and been proactive with determining any type of preventative measures for them. All her information for the residents had been data driven. -Attended care conferences to assist the interdisciplinary care team with reviewing the care plans on the residents and with their representatives. -Been a part of the care conference to ensure the care plan was accurate and true to support care for the residents had occurred. -Been a part of determining processes and preventative measures for their residents to ensure proper care and services were delivered. She had completed her interviews as directed by the MDS document, but there was nothing further to support her information for that assessment was accurate. She stated: -The other MDS nurse attends all the care conferences, I don't. -I just came back to help them with the MDSs, and here I am still here after all this time. Interview on 10/17/19 at 11:23 a.m. with the director of nursing and the administrator regarding resident 74 revealed they: Would have expected a team approach on determining preventative interventions for the high risk residents. Had been uncertain as to when and where the resident had acquired the pressure injury to his left heel. Agreed: -He was at high risk for skin breakdown, and preventative measures should have been put in place to ensure that did not occur at the time of his admission. -The dressing change was not completed in a sanitary manner and created the potential for the wound to acquire an infection and slow down the healing process. Were positive he had been admitted with that wound but could not find the documentation to support it. Agreed all the documentation had supported: -He acquired a pressure injury while receiving care and services from them. -The preventative measures and interventions were not timely and appeared to be reactive versus proactive. Were aware the MDS assessment nurse was not: -Involved in determining preventative measures to ensure skin breakdown had not occurred. -A part of care conferences and should have been to ensure the necessary care and services the residents required had occurred. Had not considered the pocket care plans as a part of the resident's comprehensive care plan. -Those were used by the staff to guide them with care for the residents. -The information on them should have been on the comprehensive care plans. -They were updated as needed and reviewed everyday in their morning stand-up meetings. Confirmed and agreed: -The admission nursing assessment of the resident had not been completed until eight days after his admission. -The admission nursing assessment should have been completed at the time of his admission and sooner then eight days. -If there was no documentation it did not happen. 3. Review of the provider's (MONTH) (YEAR) Pressure Ulcers/Skin Breakdown - Clinical Protocol policy revealed: The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). The physician and staff will examine the skin of a new admission for ulcerations or indications of a stage I pressure area that has not yet ulcerated at the surface. -There was no documentation to support how soon a skin assessment should have been completed upon the admission to the facility. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. There were no other policies or procedures on pressure ulcers and the prevention of them given to the surveyor upon request from the DON and administrator prior to exit of the facility on 10/17/19. Review of the provider's (MONTH) 2013 Charge Nurse (RN or licensed practical nurse (LPN)) job description revealed: The charge nurse performs the primary functions of an LPN or RN including assessing, planning, implementing and evaluating the care of a designated group of residents in a designated time frame. Performs and documents resident assessments on admission and on a continuing basis. Develops and updates the nursing care plan. Meets with an interdisciplinary team quarterly to review the plan of care on primary residents. Implements the plan of care, using appropriate nursing actions. Review of the provider's (MONTH) (YEAR) Clinical Coordinator job description revealed: The MDS (Minimum Data Set) Clinical Coordinator is a registered nurse (RN) that conducts federally mandated assessments for the residents at (facility name). The MDS Clinical Coordinator: -Is responsible to formulate and implement individual care plans for residents. -Will gather information from residents and their families during initial and periodic interviews. -Is to know the residents extremely well, have a good rapport with them and with their family (as well as the staff). -Are responsible to know what is going on in the facility, who is declining, med (medication) changes that are significant, etc. -Assesses, plans, implements, and coordinates the nursing care in conjunction with the Director of Nursing to ensure the highest quality of resident care is maintained at all times. -Supervises the day to day nursing activities in accordance to compliance with current Federal, State, and local standards, guidelines, and regulations that govern our facility as well as responsible to support, mentor, and empower the nursing staff.	2020-09-01
190	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	698	D	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow professional standards for the daily monitoring of one of two sampled residents' (58) [MEDICAL TREATMENT] shunt per the facility policy. Findings include: 1. Observation and interview on 10/16/19 at 10:24 a.m. with resident 58 revealed she: Had been in her room resting in the recliner. Was alert, oriented, and capable of making her needs known. Stated: -I just got back from [MEDICAL TREATMENT] so I'm resting a bit. -I go every Monday, Wednesday, and Friday. Had a shunt for [MEDICAL TREATMENT] placed in her upper left arm. Review of resident 58's medical record revealed: She was admitted on [DATE]. Her primary admission [DIAGNOSES REDACTED]. She had required [MEDICAL TREATMENT] services for her [MEDICAL CONDITION] three times a week. Interview on 10/16/19 at 10:31 a.m. with registered nurse (RN) R regarding resident 58 revealed he: Confirmed the resident went for [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Would have assessed her shunt site on the days she went out for [MEDICAL TREATMENT]. He would not have assessed the resident or her shunt site on any other days for: -A thrill/bruit. -Pain and discomfort. -Hydration and fluid balance was adequate. -Signs and symptoms of infection. -Bleeding, signs of [MEDICAL CONDITION], and [MEDICAL CONDITION]. -A change in her mental condition. -High blood pressure, fatigue, and dry or itchy skin. -A change in her urinary pattern. Review of resident 58's 10/1/19 through 10/31/19 treatment assessment record (TAR) revealed no documentation to support the nursing staff had been assessing her shunt site at all. Review of resident 58's 10/8/19 physician's orders [REDACTED]. Review of resident 58's [MEDICAL TREATMENT] information and assessment forms from 10/1/19 through 10/17/19 confirmed the nursing staff would: Have only assessed her shunt site on the days she had received [MEDICAL TREATMENT] services. Not have assessed her shunt site daily for the above areas per the facility policy. Interview on 10/17/19 at 10:35 a.m. with the director of nursing revealed she: Was not aware the nursing staff had not been completing daily [MEDICAL TREATMENT] assessments on the resident. Confirmed: -They should have been completing those assessments daily per the facility policy. -If it was not documented the assessment had not been completed. Review of the provider's (MONTH) (YEAR) Care of Resident Receiving [MEDICAL TREATMENT] Services policy revealed: Upon admission of a resident receiving [MEDICAL TREATMENT] or an existing resident who is beginning [MEDICAL TREATMENT] the nurse shall obtain a physician's orders [REDACTED]. Assessment guidelines might include but are not limited to condition of the shunt site, assessing for: -Thrill/bruit everyday. -Pain or discomfort. -Hydration and fluid balance. -Signs or symptoms of infection. -Bleeding and [MEDICAL CONDITION]. -[MEDICAL CONDITION], change in mental condition, and hypertension. -Fatigue, change in urinary pattern, and dry or itchy skin.	2020-09-01
191	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	726	G	1	0	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, personnel record review, job description review, and policy review, the provider failed to ensure one of two licensed nurses (K) was competent in recognizing the signs and symptoms of a significant change in condition for one of one closed sampled resident (380). Findings include: 1. Review of resident 380's closed medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and he had a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider was asked to see him while in the building on rounds. -An order was received from his primary care provider to send him to (hospital name) emergency department for evaluation. -The non-emergency number was contacted, and the resident left the faciity on a stretcher. Review of the Neuro (neurological) flow sheet for resident 380 revealed: The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then every hour for four hours, then every eight hours for a total of twenty-four hours. -Areas to be evaluated included level of consciousness (L[NAME]), pupil response to light, hand grip strength, vital signs, and response to verbal directions. On 9/22/19 at 7:00 a.m.: -He was alert. -His pupil response was not verified due to his eyes being shut. -The grip strength on his right hand was weak, and his left hand was strong. -His vital signs included: blood pressure (B/P) 139/68, temperature (T) 98.5 degrees, pulse (P) 78, and respirations (R) 18. -He was not responding to verbal directions. On 9/22/19 at 7:30 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -His vital signs included: B/P 135/72, T 96.9, P 68, and R 20. -He was not responding to verbal directions. On 9/22/19 at 8:00 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -His vital signs included: B/P 148/79, T 95.4, P 79; and R 24. -He was not responding to verbal directions. On 9/22/19 at 8:30 a.m.: -He was alert. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -His vital signs included: B/P 158/86; T 95.8; P 88; and R 22. -No response was listed with the following of verbal directions. On 9/22/19 at 10:00 a.m.: -He was unresponsive. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -His vital signs included his B/P at 199/85, T of 97.0, P of 63, and R of 22. -No response was listed for following of verbal directions. -The primary care provider (PCP) was present. All flow sheet entries had been completed by LPN K. Interview by telephone on 10/15/19 at 3:38 p.m. with resident 380's primary care physician regarding the events of 9/22/19 revealed: He had arrived later than his normal time frame to see residents but did not give a time frame. He was in the building seeing other residents when staff alerted him the resident needed to be assessed. Verbalized it was approximately 10:30 a.m. to 11:00 a.m. when he saw the resident. Observed him in the wheelchair rocking and slightly incoherent. The information shared with him by the nursing staff indicated: -They had telephoned the on-call provider immediately following the fall. -The on-call provider did not feel he had been significantly injured from the fall. He was surprised the staff had not called the on-call provider back regarding his change in condition. -He felt they might not have done that since they knew he would be in the facility for rounds. He thought the resident was likely experiencing a stroke or a bleed when he was assessed. It would be his expectation the resident should have been transferred to the emergency department for evaluation for his acute change in condition. There was no written progress note of his assessment of the resident. Interview by telephone on 10/15/19 at 3:44 p.m. with registered nurse (RN) N regarding resident 380 on 9/22/19 revealed: She had worked the overnight shift on another unit but was still in the building. She was asked to assist for a fall she was told looks weird. Her observation indicated: -There was no facial droop but something seemed off. -His hand grip strength was weak on both sides. -He was responding slower than his normal, and his speech was garbled. -One arm appeared to be flinching or cringing, and she was not sure if he was in pain. She told LPN K, He's not right. His baseline was he would not always answer questions appropriately but would respond. LPN K addressed her feedback with, I am assessing him, and I'll take care of it. In her nursing judgement of that day she stated she would have sent him in to be evaluated right away. Interview on 10/16/19 at 9:46 a.m. with LPN K regarding resident 380 on 9/22/19 revealed: He had been dressed for the day and was sitting in his wheelchair at the nurses station when she arrived to work at 6:00 a.m. -He would frequently propel himself in the wheelchair around the facility. -She encouraged him to stay at the nurses' station, but he had chosen to go back to his room. She entered his room to complete a blood sugar check around 7:00 a.m. to 7:15 a.m. He was laying on the floor and was slightly on his right side. -His nose was bleeding, and he was fumbling with his dentures that had fallen out. She summoned the assistance of several other staff to assist. She placed a call to the on-call physician. -The vital signs and range of motion had been completed, but neurological checks had not been completed. -The physician asked if he was comfortable or in any pain. She felt he was not in any pain. -He requested the resident be moved from the floor and receive a full assessment. If there was any concerns he was to be called back. -Acknowledged she did not tell the provider she thought he should be transferred to the hospital for evaluation. He was moved from the floor to his bed for a complete assessment. -Neuro checks were completed. Attempted to use the pen light to his eyes, but he had them shut tight. The second set of vital signs completed at 7:30 a.m. were acceptable, but he was not following commands. -Verbalized that was not abnormal as he was sometimes stubborn. She made the decision to bring him out to the nurses' station. -She was the only nurse assigned to that unit. -She wanted to be able to observe him. Staff had decided to take him to the dining room. -He was unable to eat or drink. -She felt that action might have accounted for the gap between 8:30 a.m. to 10:00 a.m. with his vital signs and neuro assessments. She felt the resident had a change in condition and needed to be transferred around 9:00 a.m. to 9:30 a.m. -Was not able to locate his preferred hospital in the medical record. -Telephoned the facility administrator a second time. -Was not able to reach the resident's spouse by telephone following the event. She was not sure when the resident's provider had arrived but felt it was after 9:00 a.m. -He had ordered the resident to be transferred to the emergency department for evaluation. She acknowledged her actions were done using her own nursing judgment and not based on a facility policy or procedure. -The policy and procedures had been given to her upon being hired, but she was not sure were they were currently located. She could not recall completing any recent skill competencies. Acknowledged he had been sent to the emergency department by non-emergent transfer. -Was not able to give a rationale for a non-emergent transfer and stated it just happened that way. Review of the hospital medical record for resident 380 revealed: He had arrived at the emergency department at 11:21 a.m. A physician's note on 9/22/19 at 2:31 p.m. indicated: -Patient (resident) is a level I stroke code upon arrival .Initial last normal time is not clear however this was verified to be at 6:30 a.m., and unfortunately he is past the TPA (tissue plasminogen [MEDICATION NAME] - a protein used to breakdown clots) window. -We did call the nursing home to verify last known well. At 6:30 a.m. he was able to get up in his chair and was acting normal per the nurse. It is not clear why there was a delay before he was brought to the ED. -On arrival the patient is not moving his left side he does have complete [MEDICAL CONDITION] and is nonverbal and looking to the right. His [DIAGNOSES REDACTED]. A physician's note on 9/24/19 at 12:36 p.m. indicated: -R MCA (right middle cerebral artery) stroke with large volume hemorrhage within the stroke zone, with the development of uncal herniation. Per discussion with the patient's family, decision made to transition to Comfort/Hospice. He passed away in hospice care on 9/24/19. Review of LPN K's personnel file revealed: Her hired date was 5/18/16. She had completed a nurse competency checklist on 5/18/16. -It included the policy and procedure related to incident and fall reports. -There was no indication the emergency and change in condition policies and procedures were reviewed. No additional competencies were found in her employee file. Review of the (MONTH) 2013 Charge Nurse (RN or LPN) job description revealed essential functions included: Observes, records, and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. *Knows and is able to carry out approved emergency procedures. Review of the 8/15/19 Neurological Assessment policy revealed: Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.	2020-09-01
192	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	740	G	0	1	SJ6G11	Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure one of one sampled resident (50) who was socially withdrawn and unhappy with her placement in the facility received any social services or behavioral health services. Findings include: 1. Interviews and observations on 10/15/19 at 3:00 p.m. and on 10/16/19 at 9:45 a.m. of resident 50 revealed she: Was alert and oriented to person and place. Laid on her bed with no clothes on except a disposable brief. -Showed no discomfort with how she was dressed in the surveyors presence. Stated loudly, This place sucks and went on to say how unhappy she was there. -Felt like she was just put in the facility to die, and all the staff cared about was getting her money. -Did not care how she got out of this place, but she thought it would take dying to get out. -Did not go to any activities and emphatically stated she did not care to go. -Did not know who the social worker was or that she had a social worker to visit with. -Had a computer she thought she should bring into her room but did not know where it was. -Went to the dining room for breakfast and lunch but not supper. --Did not visit with any peers and was unhappy with the other residents in the dining room. Review of resident 50's 9/10/19 Minimum Data Set (MDS) assessment revealed she: Was cognitively intact. Felt down and depressed. Was tired and had little energy. Interview on 10/16/19 at 10:16 a.m. with certified nursing assistant C regarding resident 50 revealed she had: Known her from the previous nursing home she was at. -A history of failure to thrive. Interview on 10/17/19 at 7:48 a.m. with certified medication aide D regarding resident 50 revealed she: Did not like to get dressed, and laid in bed without any clothes on. Got upset about being here and cried. Could get upset about wanting to get a can of pop. She was not always cooperative with her bath. She had never seen any visitors. Review of resident 50's social services notes revealed: 6/25/19: She scored a 6/27 on the pHQ9 (an assessment of depression) indicating depression concerns at this time. She expressed that she feels this is as she has no control of her situation and has no one as intelligent that she is able to interact with her. -No noted moods or behaviors during that look back period. -Length of stay was long term. 7/2/19: Care conference summary: -Resident refused to participate in the care conference. -She refused every attempt to weigh her. -Her food intake varied depending on her mood. -Refused all structured activities but did like one-to-ones. -A medication for her mood and anxiety had been increased by her physician since her admission. -She continued to be unhappy with multiple things but was unwilling to give specifics. -She made general statements like nothing works and thought the food was terrible. 7/24/19: Social worker (SW) went to speak with her about her emotional state offering a mental health counselor. -She declined. -She became tearful and stated she did not want to be there anymore. -Discharge was discussed with her, but she stated she had no where to go. There was no further weekly visits or follow-up with her on barriers to her adjustment to the facility or the possibility of other placement. Review of resident 50's 6/26/19 care plan revealed: Problem/Strengths: She had signs and symptoms of depression. Interventions: -Administer medications. -Monitor for signs of depression. -Involve in activities daily. -Notify MD immediately of suicidal ideation, self harming. -Social services to encourage resident to verbalize feelings, provide validation and reassurance as needed. -Social services and activities: In room visits for social stimulation if resident could not attend activities. -Psych (psychiatric) consult as indicated. Interview on 10/17/19 at 9:30 a.m. with the director of nursing regarding resident 50 revealed: She liked to be in her room undressed and did not want the door closed. -Had a blanket that was with her to pull up over her. She had a call light but did not always use it. She stayed in bed as much as possible and had snacks in her room. It was all about the approach with her, smile and soft tones. She complained about being in the facility, and it depended on how she felt whether she would cooperate with staff. She said herself she was racist and did not like the staff of color. So they always tried to have a white staff person with her when care was given to her. Interview on 10/17/19 at 8:31 a.m. with SW W regarding resident 50 revealed: He had not visited with her for emotional support, and he really had not spent any time with her. The SW that recently quit had completed the MDS. Counseling had been offered, but she had refused. He agreed nothing had been done with her, and he really did not know her well. He confirmed she was a resident who had psychosocial issues and could have benefited from more frequent contact. Review of the provider's (MONTH) (YEAR) Social Worker job description revealed: The role of the SW in a long term care facility is to enable each individual to function at the highest possible level of social and emotional wellbeing and to act as the resident advocate in all circumstances. Essential functions: -Assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights, and accommodation of needs. -Assisting or arranging for a resident's communication of needs through the resident's primary method of communication or in a language that the resident understands. -Making arrangements for obtaining items. Ensure that the facility provides social services or obtains needed services from outside entities include, but are not limited to: -Expressions or indications of distress that affect the resident's mental and psychosocial well-being , resulting from depression, chronic diseases, difficulty with personal interaction and socialization skills, and resident to resident altercations. -Difficulty coping with changes or loss (e.g. change of living arrangement). -Need for emotional support.	2020-09-01
193	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	803	E	0	1	SJ6G11	Based on observation and interview, the provider failed to ensure seven of eight randomly observed residents in[NAME]Wing dining room received the appropriate amount of protein during the evening meal by one of one observed dietary cook (O). Findings include: 1. Observation and interview on 10/15/19 from 5:40 p.m. through 5:55 p.m. with dietary cook O during the evening meal service in the[NAME]Wing dining room revealed: He began to serve the evening meal at 5:45 p.m. While serving out the meat mixture he would alternate between putting two or three scoops of the meat mixture on the buns. Of the eight randomly observed residents seven residents received two scoops of the meat mixture on their bun. One resident had received three scoops of the meat mixture on the bun. Interview and observation on 10/15/19 at 5:55 p.m. with dietary cook O and review of the scoop sizes he used during the evening meal revealed: The scoop used for the meat mixture had the number 40 on it. He had given the residents two scoops of the meat mixture. They usually used a blue scoop, but there was not one. Interview on 10/15/19 at 6:10 p.m. with dietary manager B regarding the above observed evening meal revealed: They had broken a lot of the scoops. She had checked the menu on[NAME]Wing, and the residents were to have received three ounces of the meat mixture. She had checked the scoop size and confirmed it had been a one ounce scoop. -The residents would have needed to receive three scoops to get the full three ounce portion. The dietary cook had not used the correct scoop. Interview on 10/17/19 at 8:30 a.m. with the administrator regarding the evening meal on 10/15/19 in the[NAME]Wing revealed: Each kitchenette had a copy of the scoop sizes. Her expectations would have been for the dietary cook to have used the correct scoop size. If a certain scoop was broken she would have expected the staff to know how to use a correct scoop to get the correct portion size. *They were in the process of purchasing new kitchen supplies. Review of the provider's undated Disher Scoop Sizes, Colors and Yields revealed: Scoop size #40 yields .80 fluid ounces.	2020-09-01
194	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	842	D	1	0	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on closed record review, interview, job description review, and policy review, the provider failed to have complete documentation for one of one closed sample resident (380). Findings include: 1. Review of the medical record for resident 380 revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set assessment showed: -A Brief Interview of Mental Status score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the information face sheet for resident 380 revealed the preferred hospital line had been left blank. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: An effective date of 7/25/19. Problems/Strengths: At risk for falls related to balance problems during transfers. Goals: -No falls. -Would be free from injury related to fall. Interventions: -Would receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and he had a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider was asked to see him while in the building on rounds. -An order was received from his primary care provider to send him to (hospital name) emergency department for evaluation. -The non-emergency number was contacted, and resident left the faciity on a stretcher. Review of the fall report for resident 380 revealed: It had occurred at 7:00 a.m. on 9/22/19. He was unable to give an explanation of the event that had occurred and was unresponsive. He had a history of [REDACTED]. The area of the form for physician signature of notification had been left blank. Review of the Neuro (neurological) flow sheet for resident 380 revealed: The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then every hour for four hours, then every eight hours for a total of twenty-four hours. -Areas to be evaluated included level of consciousness (L[NAME]), pupil response to light, hand grip strength, vital signs, and response to verbal directions. On 9/22/19 at 7:00 a.m.: -He was alert. -His pupil response was not verified due to his eyes being shut. -The grip strength on his right hand was weak, and his left hand was strong. -The vital signs included: blood pressure (B/P) 139/68, temperature (T) 98.5 degrees, pulse (P) 78, and respirations (R) 18. -He was not responding to verbal directions. On 9/22/19 at 7:30 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 135/72, T 96.9, P 68, and R 20. -He was not responding to verbal directions. On 9/22/19 at 8:00 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 148/79, T 95.4, P 79, and R 24. -He was not responding to verbal directions. On 9/22/19 at 8:30 a.m.: -He was alert. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 158/86, T 95.8, P 88, and R 22. -No response was listed with the following of verbal directions. On 9/22/19 at 10:00 a.m.: -He was unresponsive. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 199/85, T 97.0, P 63, and R 22. -No response was listed for following verbal directions. -The PCP was present. All flow sheet entries had been completed by LPN K. Review of the physician's orders [REDACTED]. 9/22/19 - Head Injury with poor responsiveness- Recommend evaluate in (hospital name) ED. -It was signed by the resident's primary care provider (PCP). It was noted by LPN K and dated 9/22/19. There was no time listed by the physician or LPN K signatures. Interview on 10/15/19 at 3:02 p.m. and again at 3:56 p.m. with the director of nursing regarding the events on 9/22/19 regarding resident 380 revealed: She acknowledged the fall report stated he was unresponsive at 7:00 a.m., but clarified he was only in that state upon initial observation. Verbalized the medical records department was responsible for placing the preferred hospital on the information face sheet. Verified the physician order [REDACTED]. Interview by telephone on 10/15/19 at 3:38 p.m. with resident 380's primary care provider regarding the fall on 9/22/19 revealed: Verbalized it was approximately 10:30 a.m. to 11:00 a.m. when he saw the resident. Observed him in the wheelchair rocking and slightly incoherent. The information shared with him by the nursing staff indicated: -They had telephoned the on-call provider immediately following the fall. -The on-call provider did not feel he had been significantly injured from the fall. He was surprised the staff had not called the on-call provider back regarding his change in condition. -He felt they might not have done that since they knew he would be in the facility for rounds. He thought the resident was likely experiencing a stroke or a bleed when he was assessed. It would be his expectation the resident should have been transferred to the emergency department for evaluation for his acute change in condition. There was no written progress note of his assessment of the resident. Interview on 10/15/19 at 4:10 p.m. with the director of medical records regarding the information face sheet for resident 380 revealed: She would have entered the preferred hospital in the appropriate field if known. The process at the time of the event involved the social worker forwarding that admission information to her. Interview on 10/15/19 at 4:15 p.m. with social worker W regarding the information face sheet for resident 380 revealed: He initially verbalized it was a duty of the medical records department. -He had been provided information regarding the above interview with medical records. He described the absence of a preferred hospital on the form as a data-entry error, and there was no good reason why it had occurred. The process in place at the time of the resident's admission and the above event indicated: -He would collect and send out the resident's information to the appropriate departments approximately two days prior to admission. -It had been his responsibility, but there was no policy and procedure in place. Interview on 10/16/19 at 9:46 a.m. with LPN K regarding resident 380 on 9/22/19 revealed: He had been dressed for the day and was sitting in his wheelchair at the nurses station when she had arrived to work at 6:00 a.m. She entered his room to complete a blood sugar check around 7:00 a.m. to 7:15 a.m. He was laying on the floor and was slightly on his right side. -His nose was bleeding, and he was fumbling with his dentures that had fallen out. She summoned the assistance of several other staff to assist. She placed a call to the on-call physician. -The vital signs and range of motion had been completed but neurological checks had not been completed. -The physician asked if he was comfortable or in any pain. She felt he was not in any pain. -He requested the resident be moved from the floor and receive a full assessment. If there was any concerns he was to be called back. -Acknowledged that she had not told the provider that she thought he should be transferred to the hospital for evaluation. He was moved from the floor to his bed for a complete assessment. -Neuro checks were completed. Attempted to use the pen light to his eyes, but he had them shut tight. The second set of vitals completed at 7:30 a.m. were acceptable, but he was not following commands. -Verbalized that was not abnormal as he was sometimes stubborn. She made the decision to bring him out to the nurses' station. Staff had decided to take him to the dining room. -He was unable to eat or drink. -She felt that action might have accounted for the gap between 8:30 a.m. to 10:00 a.m. with his vital signs and neuro assessments. She felt the resident had a change in condition and needed to be transferred around 9:00 a.m. to 9:30 a.m. -She was not able to locate his preferred hospital in the medical record. -She telephoned the facility administrator and nurse back. -She was not able to reach the resident's spouse by telephone following the event. She was not sure when the resident's provider had arrived but thought it was after 9:00 a.m. -He had ordered the resident to be transferred to the emergency department for evaluation. She acknowledged her actions were done using her own nursing judgment and not based on a facility policy or procedure. Acknowledged he had been sent to the emergency department by non-emergent transfer. -Was not able to give a rationale for a non-emergent transfer and stated, It just happened that way. Review of the 9/22/19 to 9/24/19 hospital medical record for resident 380 revealed: He arrived at the emergency department at 11:21 a.m. A physician's note on 9/22/19 at 2:31 p.m. indicated: -Patient (resident) is a level I stroke code upon arrival .Initial last normal time is not clear however this was verified to be at 6:30 a.m., and unfortunately he is past the TPA (tissue plasminogen activator - a protein used to breakdown clots) window. -We did call the nursing home to verify last known well. At 6:30 a.m. he was able to get up in his chair and was acting normal per the nurse. It is not clear why there was a delay before he was brought to the ED. -On arrival the patient is not moving his left side he does have complete [MEDICAL CONDITION] and is nonverbal and looking to the right. His [DIAGNOSES REDACTED]. A physician note on 9/24/19 at 12:36 p.m. indicated: -R MCA (right middle cerebral artery) stroke with large volume hemorrhage within the stroke zone, with the development of uncal herniation. Per discussion with the patient's family, decision made to transition to Comfort/Hospice. He passed away in hospice care on 9/24/19. Review of the employee file for LPN K revealed a document signed on 7/22/19 indicating: I have read the documentation requirements .and understand my responsibilities and obligations for charting as as nurse. Review of the (MONTH) 2013 Job Description for Charge Nurse revealed the essential functions included to monitor and document changes in the health status of a resident through continuing assessment. [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis., (YEAR), p. 362, revealed: You need to ensure that the information within a recorded entry or a report is complete, containing appropriate and essential information.	2020-09-01
195	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	867	G	0	1	SJ6G11	Based on observation, record review, interview, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to residents' care within the facility. Findings include: 1. Interview on 10/17/19 at 2:59 p.m. with the administrator regarding their QAPI program revealed: She was the QAPI coordinator. They would like to do monthly meetings but had been meeting quarterly. -They were due for their next quarterly meeting in October. They currently had a medical director. -They were in the process of finding a new medical director. Their last QAPI meeting was in (MONTH) or July. The medical director had not attended all of the quarterly meetings. -They would email information to the medical director if they were unable to attend. They used the Casper report for their QAPI meetings. Each department reported on what they had been working on. The pharmacist had attended the quarterly QAPI meetings. They were not working on any performance improvement plans (PIPS). -They knew they had issues. -They had not had the resources or staff to initiate PIPS or to follow through on the PIPS. Review of the QAPI Sign-In Sheet from (MONTH) 11, (YEAR) through (MONTH) 26, 2019 revealed the medical director had attended the QAPI meetings in (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019. Review of the provider's 2019 QAPI Plan revealed: Purpose: -To promote the highest quality of life for our residents while providing quality care. The QAPI plan included policies and procedures used to:-Identify and use data to monitor our performance. -Establish goals and thresholds for our performance measurements. -Utilize resident, staff and family input. -Systematically analyze underlying causes of systemic problems and adverse events. -Develop corrective action or performance improvement activities. (Facility name) will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention. -We will conduct PIPS that will lead to changes and guide corrective actions in our systems, which cross multiple departments, and have impact on the quality of life and quality of care our residents. The QAPI committee will review data and input on a monthly basis to look for potential topics for PIPS. QAPI committee will prioritize topics for PIPS based on the current needs of the residents and (facility name). Refer to F550, F565, F584, F604, F610, F641, F657, F658, F679, F684, F686, F698, F726, F740, F803, F842, and F880.	2020-09-01
196	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	880	E	0	1	SJ6G11	Based on observation, interview, record review, policy review, and manufacturer's recommendations review, the provider failed to ensure appropriate infection control practices and protocols were followed for: Glove use and hand hygiene during: -Residents' personal care -Cleaning of residents' rooms. Cleaning and disinfecting of two of two residents (2 and 73) glucometers by one of one observed licensed nurse (R). Two of two sampled residents (74 and 235) observed dressing changes by one of one observed licensed nurse (R). Maintaining a sanitary environment for: -One of one storage room that had resident use items stored inside of it. -One of three medication rooms (east wing) that was not clean. -Two of two observed tub rooms (central and east). -One of one resident (38) observed dressing change with one of one registered nurse (RN) I. Findings include: 1. Observation on 10/16/19 from 11:15 a.m. through 11:30 a.m. with registered nurse (RN) R during observations of residents' blood sugar checks revealed: At 11:20 a.m.: -He gathered the supplies and went to resident 73's room. -She was not in her room. -He went to the therapy room where she was, and he checked her blood sugar. -Returned to the medication cart, took out a Chlorox wipe, wiped the glucometer off, and left it to air dry. At 11:30 a.m.: -He gathered the supplies and checked resident 2's blood sugar. -Returned to the medication cart, took out a Chlorox wipe, wiped the glucometer off, and left it to air dry. Interview at the above time with RN R regarding the cleaning of the glucometers revealed: Each resident had their own glucometer with their name on it. Each glucometer was stored separately in the medication cart. That was his usual practice for cleaning the glucometer off after each use. Review of the provider's 5/3/17 Single Resident Use Glucometers policy revealed: Glucometers will be cleaned per manufacture's guidelines after each use and when quality controls are completed. Review of the Assure Prism Blood Glucose Monitoring System User Instruction Manual, pages 38 and 39, revealed: Page 38: -The meter should be cleaned and disinfected after use on each patient (resident). Page 39: -We have validated Chlorox Germicidal wipes for disinfecting the Assure Prism multimeter. -Please read the instructions provided by the manufacturer of Chlorox Germicidal wipes. Review of the Chlorox Bleach Germicidal Wipes manufacturer's recommendation label on the bottle revealed: To clean and disinfect and deodorize hard, nonporous surfaces: -Wipe surface to be disinfected. -Use enough wipes for treated surface to remain visibly wet for the contact time listed below. -Let air dry. Contact time: -Bloodborne pathogens: one minute. 2. Observation and interview on 10/16/19 at 4:20 p.m. with RN R in resident 235's room revealed: He gathered the supplies and went to resident 235's room. He walked into the room and laid the supplies on the wheelchair cushion without first laying down or creating a barrier. The resident had an opened wound to his right foot bunion area that had been draining. He was laying on the bed with a shoe on his left foot, and his shoe and sock were next to his right foot. Interview at the above time with RN R regarding the dressing change for resident 235 revealed: He thought the wheelchair cushion was a better place to put the dressing supplies. -The resident would keep his urinal on the overbed table, and he did not have time to clean it off prior to laying the dressings down. -He did not think it was an infection control breach for laying the supplies on the wheelchair cushion. Interview was done on 10/17/19 at 7:35 a.m. with the director of nursing (DON) regarding the above dressing change for resident 235 done on 10/16/19 with RN R revealed: She would have expected him to have laid down a barrier before laying the dressing supplies down. 3a. Observation on 10/15/19 at 3:31 p.m. of certified nursing assistants (CNA) M and P with resident 74 revealed: He had been in his room sitting in his wheelchair (w/c). He had a Foley catheter collection bag hanging from underneath his w/c. The CNAs had prepared to assist him with catheter care and a transfer from his w/c onto his bed. He had required the use of a mechanical lift to assist him with transfers. They sanitized their hands prior to entering his room and put on clean gloves. -With those clean gloves on CNA M removed a pillow that was hanging from his w/c. -Unhooked the catheter bag from his w/c. --She removed her gloves and put on a clean pair without washing or sanitizing her hands. CNA M: -Went out of the room and got the standaide mechanical transfer lift to transfer the resident. -Helped CNA P with putting the transfer sling in place and on the resident. -Secured the safety strap around the resident's legs. -Used the remote control on the standaide and stood the resident up. -Pulled down the resident's pants and removed the soiled incontinent brief. -Removed her gloves and without sanitizing or washing her hands put on another clean pair. CNA P: -Opened a cupboard and got out a clean brief and a package of wet wipes. -Placed the wet wipes on his bedside table, opened them, and took several of the wipes out of the package. -Took the wet wipes and cleaned his bottom first. He had been incontinent of bowel movement (BM). -Took more wet wipes and cleaned his front and the catheter insertion site after cleaning BM off of his bottom. -Took a tube of barrier cream, opened it, and put some in CNA M's hand. --CNA M put the cream on the resident's bottom. They removed their gloves and without sanitizing or washing their hands put on another pair of gloves. With those gloves on, they put on a clean brief, pulled up his pants, and assisted him to lay down on his bed. -They removed their gloves and without washing or sanitizing their hands left the room. CNA M had left one glove on to take the garbage out and deposit it in the soiled utility room. Both of the CNAs sanitized their hands and went to assist the next resident. -That was the only time they were observed sanitizing their hands during the entire process above. b. Observation on 10/15/19 at 3:47 p.m. of CNAs M and P with resident 4 revealed: He had been in his room sitting in his w/c watching television (TV). They had prepared to assist him with personal care, suprapubic catheter care, and a transfer onto his bed. He had required the use of a full body mechanical lift for transfers. They sanitized their hands and put on clean gloves. His Foley catheter bag had been full of urine and required emptying. CNA M emptied the catheter collection bag of its contents and removed her gloves. Without washing or sanitizing her hands she put on another pair of gloves. CNA P: -Opened the bathroom door, touched the faucet handle, and turned on the water. -Got a plastic wash basin and put it in the sink to fill it with water. -Took off the resident's shirt, got a washcloth, and wet it with the water from the basin. -Washed his face, upper torso, and arms with that washcloth. -Took a hand towel and dried him off. -Placed both of the dirty towels on the edge of the bathroom sink. That bathroom had been shared with the resident in the room next door. Removed her gloves and without washing or sanitizing her hands put another pair on. With those gloves on CNA P assisted CNA M: -With placing the total body sling underneath of him and transferred him onto the bed. -Removed his pants and soiled incontinent brief. His incontinent brief was soiled with BM. Both of the CNAs changed their gloves without sanitizing or washing their hands. CNA P: -Opened a package of wet wipes and took several of them out. -Got a bottle of perineal cleanser and sprayed the wet wipes with them. -Used those wet wipes to wash the suprapubic site and front area. -Took out several more wet wipes, put cleanser on them, and cleaned his bottom. They removed their gloves and put on another pair without sanitizing or washing their hands. They finished assisting the resident positioning in his bed, removed their gloves, and washed their hands. -That had been the first time they were observed washing or sanitizing their hands during the entire process above. c. Observation on 10/15/19 at 4:57 p.m. of CNAs M and P with resident 11 revealed: He had been laying in bed and was ready to get up for supper. The CNAs prepared to assist the resident with personal care and a transfer from his bed into a w/c. He had required the use of a standaide for transfers. The CNAs: -Sanitized their hands and put on a clean pair of gloves. With those gloves on CNA P: -Assisted CNA M with pulling down his pants and removing his incontinent brief. -Opened a package of wet wipes and took out several of them. -Took the wet wipes and cleaned his bottom first. -Took more wet wipes and then cleaned his front. Both of them changed their gloves without washing or sanitizing their hands. They: -Assisted the resident with dressing and transferring into his w/c. -Removed their gloves and washed their hands. --That had been the first time they were observed washing or sanitizing their hands during the entire process above. d. Interview on 10/15/19 at 5:13 p.m. with CNAs M and P regarding the observations above revealed: That had been their usual process for providing personal care and catheter care for the residents. They had not recognized their process as unsanitary until after the observations were reviewed with them. They agreed: -The personal and catheter care provided above had not been completed in a sanitary manner and placed the residents at risk for acquiring an infection. -They should have removed their gloves and washed or sanitized their hands after they had been soiled and between changing them. CNA P agreed the resident's front area should be cleaned before the bottom. 4. Observation on 10/16/19 at 10:39 a.m. with RN R with resident 74 revealed: The resident was in his room sitting in his w/c watching TV. He had the Una boots on both of his feet. RN R: -Had prepared to complete the dressing change to the resident's left heel pressure injury. -Sanitized his hands and put on clean gloves. -Removed the resident's Una boot and sock from his left foot. There had been no dressing on the resident's left heel for protection. With those dirty gloves on RN R: -Touched and felt the wound prior to showing it to the surveyor. --The pressure injury was located on the lateral aspect of his left heel. -Opened a package of 4x4 gauze and moistened it with wound cleanser from a bottle. -Cleaned the wound with that 4x4 gauze. -Put the resident's foot back down to rest on the Una boot. --The pressure injury came into direct contact with the outside surface of that Una boot. RN R: -Removed his gloves and without sanitizing or washing his hands put on another pair of gloves. -Opened the package containing the Sorbact gel gauze, removed it from the package, and placed it on the resident's opened wound. -Opened another package and placed a protective dressing over the wound. -Removed his gloves and put the resident's sock and Una boot back on. Interview on 10/16/19 at 10:55 a.m. with RN R regarding the above observation with resident 74 revealed he: Agreed: -The dressing change was completed in an unsanitary manner. -A treatment completed in an unsanitary manner would have created the potential for poor healing and infection to have occurred. Had not realized: -All the surfaces he touched would have been considered dirty until reviewed with him. -He had touched and assessed the resident's wound with dirty gloves on. Was not sure if that was his usual process for completing a dressing change, as he had been looking for sanitizer and had not seen any in the resident's room. Interview on 10/17/19 at 7:48 a.m. with the DON regarding the observations revealed she: Agreed the processes above had: -Not been completed in a sanitary manner. -Created the potential for the residents to have acquired an infection. Stated: -They should always clean the catheter and front first, cleanest to dirtiest. -They should wash or sanitize their hands when changing gloves. -We have not completed any audits on personal or catheter care and should be. 5. Observation on 10/16/19 at 10:57 a.m. of the clean storage room behind the east wing nurses' station revealed: There had been several open shelves on the one side of the room. On those shelves had been supplies for resident use such as: -Packages of incontinent briefs. -Several packages containing medication administration cups. -A box full of denture cleaning tablets. -A box full of plastic spoons. -Plastic graduate containers. -Storage for the mechanical lift batteries. There was a cupboard with multiple drawers, shelving, and a counter top with a sink in it. The base board was missing from all the exposed wall areas. -That had created an uncleanable surface as the gypsum board on the walls was exposed. The covering over the light fixture had what appeared to be dirt and dead bugs in it. The entire floor surface had: -Black, gray, and white dirt particles on it. -Torn pieces of paper hand towels on it. -Medication cups on it. The counter top had a thick layer of dust on it. Interview on 10/16/19 at 10:59 a.m. with RN R regarding the observation of the room above revealed he: Confirmed the room was used to store clean supplies for the residents. Confirmed the room was not clean and should have been. Stated: The housekeeping department is supposed to be cleaning this room. Had not been sure of that cleaning process. 6. Observation and interview on 10/17/19 at 3:11 p.m. of the east wing medication room with the DON revealed: The room had several cupboards with drawers and shelves. The counter top on those cupboards had been dirty with dust on it. The floor had black, gray, brown, and white dirt particles and dust on it. Several corners in the room had cobwebs with dirt particles and dead bugs in them. The window in that room was covered with metal bars and was open to allow for cool air to come in. -The screen covering that window had lint, dust, dirt, and a fuzzy type particle from the outdoors on it. The housekeeping department was supposed to clean the room with the presence of the nursing staff. She agreed the medication room was not clean and should have been. 7. Interview on 10/17/19 at 7:48 a.m. with the DON regarding the observations revealed she: Agreed the processes above had: -Not been completed in a sanitary manner. -Created the potential for the residents to have acquired an infection. Stated: -They should always clean the catheter and front first, cleanest to dirtiest. -They should wash or sanitize their hands when changing gloves. -We have not completed any audits on personal or catheter care and should be. Review of the provider's undated Perineal Care policy revealed: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections, and skin irritation. Wash perineal area, wiping from front to back. Review of the provider's (YEAR) Hand Hygiene policy revealed: Immediately after gloves are removed, and when otherwise indicated to avoid transfer of microorganisms to other residents. Review of the provider's undated Wound Care policy revealed: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Gloves were to be changed after removal of the soiled dressing and hands washed. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. There was no process for hand hygiene and glove change or use after cleaning of a wound and prior to applying a new dressing to it. Review of the provider's (MONTH) (YEAR) Medication Storage policy revealed: Medication storage should be kept clean, well lit, organized, and free of clutter. 7a. Observation on 10/16/19 at 1:39 p.m. of the central tub room revealed: There were three combs and one brush with hair in them. There were liquid soaps and deodorants in the cupboard that were not labeled with residents' names. There were two electric razors, one on the counter and one in the cupboard. -Both razors were dirty and caked with a white powdery substance and small hairs. There was a fan on the wall, and it was covered with thick brown dust. The finish had come off the bottom board of the cupboard, and the wood was buckled. This would not have been a cleanable surface. b. Observation on 10/16/19 at 3:31 p.m. of the east tub room revealed: There was an electric razor in the cupboard labeled east razor. The inside of the razor was caked with a yellow powdery substance and small hair fragments. -There had been another razor in the cupboard that was not labeled, and it was in the same condition. A sign on the cupboard read: Electric razor use: Empty razor and use a alcohol swab to clean razor after every resident. At the end of your shift you must take razor apart and clean with alcohol. Leave razor apart until the start of the next day. There were several personal care items in the cupboard including: Cocoa Butter skin lotion, cleansing cream, Dove men care deodorant, Suave Coconut shampoo and conditioner, Pantene shampoo. -Those items had no labels or names on them. -Those items were mixed in with single-use items and items that had resident's names on them. There was a razor in the cupboard with a resident's name written on it. -When the razor was opened hair particles fell out as it was so full. -It was also caked with a yellow powdery substance and small hair fragments. The cupboard had a shelf labeled for women, and a shelf labeled for men on one side. The other side of the cupboard was a mix of multiple-use items and single-use items that did not have resident's names on them. There was a nail clipper hanging on the front of a blue basket in the cupboard. -It was rusted and caked with white debris. There was a purple brush on the women's shelf that had a resident's name on it, and it was full of hair. There was a white wire shelf on the wall that was rusted making it uncleanable. -It was holding wash clothes and hand towels. The fan on the wall was caked with gray dust particles. There was a one gallon bottle of moisturizing lotion on the floor under the cupboard. c. Interview on 10/16/19 at 1:39 p.m. with CNA F regarding the central tub room revealed: She was the bath aide. She did not know who the combs and brush belonged to. She had known who three of the items belonged to and was going to return them to those residents. -Those items did not have names on them. She did not know which residents the other items belonged to. The electric razor on the counter was the facility razor. -She only used that razor if the resident did not have their own personal razor. -When asked how she cleaned the razor she said she rinsed it off with water. She only turned the fan on when she was alone in the room cleaning the tub. She did not know who was to clean the fan. Interview on 10/17/19 at 9:17 a.m. with housekeeper G revealed housekeeping was not in charge of cleaning the fans in tub rooms. Interview on 10/17/19 at 3:45 p.m. with the DON revealed: All residents should have had their own electric razors. The facility did not have shared electric razors. The sign in the east tub room about cleaning the razors should have been removed. The razors in the tub rooms that were for multiple-use should have been removed. -Those razors probably did not work. If personal items were left in tub room they should have had the resident's name on them. Personal items should have been kept in resident's rooms. Nail clippers should have been on the medication carts, and CNAs should have asked a nurse for the nail clippers. It was housekeeping's responsibility to clean the fans on the walls. Combs and picks could be left in the tub room and cleaned in between with an alcohol wipe. Brushes should have been kept in resident's rooms. Review of the provider's (YEAR) Infection Control General Policies Cleaning, Disinfection, and Sterilization Policy provided by the administrator revealed: Razors have a semi-critical device classification. The razors should have been cleaned with Household bleach 1:10 (1 part bleach to 9 parts water). 8a. Observation on 10/17/19 at 9:17 a.m. of housekeeper G revealed: She had entered a resident's room and put gloves on with no hand hygiene observed. She moved furniture away from the wall in the room and removed her gloves. She then went out to the hallway to her cart to gather supplies, and then went back into the room and put gloves back on. -No hand hygiene was observed. She sprayed disinfectant on the sink and toilet, removed her gloves, and went back to her cart in the hallway. -No hand hygiene was observed. She returned to the room, put gloves on, and then cleaned the window blind and the window sill. She changed her gloves and washed the window. She changed her gloves and washed the mirror, then removed gloves and went back to the hallway to her cart. -No hand hygiene was observed. She returned to the room with a broom and swept the floor touching the dust pan with her bare hands. -No hand hygiene was observed. She went back into the hallway to her cart, then back into the room and put on gloves. She then sprayed the sink and toilet with bleach water. She cleaned the sink, changed her gloves, and went back to the hallway to her cart. -No hand hygiene was observed. She returned to the room, cleaned the toilet, and removed her gloves. -No hand hygiene was observed. She went back into the hallway to her cart and filled her scrub top pocket with gloves. Went back into room and put on a pair of gloves from her pocket, removed two bags of garbage, and took them back to her cart in the hallway. She then reached into her pocket with the gloves on to retrieve her keys, unlocked the cart, removed some supplies, locked the cart, put keys back in her pocket, and went back into the room. She cleaned the garbage cans, took off her gloves, and went back to the hallway to her cart. -No hand hygiene was observed. She returned to the room, mopped the floor, and then went back to her cart to put the mop away. She then walked down the hall and used the hand sanitizer on the wall. Interview on 10/17/19 at 9:17 a.m. with housekeeper G revealed: She did not know she was to perform hand hygiene when entering and leaving a room, or when changing her gloves. She was told she needed to change her gloves between each piece of furniture in the room. b. Observation on 10/15/19 at 3:35 p.m. of RN I regarding resident 38 revealed: She entered a resident's room and put on gloves. -No hand hygiene was observed. She removed two soiled bandages from the residents left leg, then she exited the room, and she removed gloves as she was walking down the hallway. -No hand hygiene was observed. She went to the treatment cart, reached into her scrub top pocket for keys, unlocked the cart, and looked through the supplies. She then took supplies back to the residents room and put on gloves. She had set the supplies on the counter next to the sink without a clean barrier under them. She then reached into her scrub top pocket, took out a black marker, and dated the clean bandages she had brought into the room. She then applied the new bandages, removed her gloves, left the room, and then used the hand sanitizer in the hallway. Interview with RN I directly after the above dressing change revealed she agreed she should have washed her hands more during the dressing change. She should not have set her supplies down without creating a clean surface. c. Interview on 10/17/19 at 3:45 p.m. with the DON and the infection control nurse revealed: They agreed that both the housekeeper and the nurse had not performed proper hand hygiene. The nurse should have had a barrier under the clean dressing supplies. The facility conducts an all staff inservice yearly on infection control. They had done handwashing audits in the past. -Those were effective as they noted more hand soap and hand sanitizer was needing to be ordered. The facility had several changes in housekeepers. It was difficult to train new housekeepers as they did not have anyone to do that. -The maintenance director trained all new housekeepers, but he was out on medical leave. d. Review of the provider's undated Wound Care policy revealed: Use disposable cloth (paper towel is adequate) to establish clean field on resident's over-bed table. Place all items to be used during procedure on the clean field. *Wash and dry your hands thoroughly. -That was to be done prior to and after removing the soiled dressing. -That was also to be done after the new dressing had been applied.	2020-09-01
197	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	679	E	0	1	YOJP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure one-on-one activities were provided for three of three sampled residents (8, 23, and 63). Findings include: 1. Review of resident 63's medical record revealed: She had been admitted on [DATE]. Her 1/3/20 admission Minimum Data Set (MDS) assessment revealed her: -Brief Interview for Mental Status (BIMS) assessment score was fifteen indicating her cognition was intact. -[DIAGNOSES REDACTED]. -Activities that were very important to her included: listening to music, being around animals, doing her favorite activities, and going outside. Review of resident 63's 1/2/20 care plan revealed: She would potentially benefit from one-on-one activity programming. She would engage in one-on-one program three to four times a week. Conduct daily motivations rounds to promote increased involvement and response to therapeutic activities. Provide leisure skill education covering the importance of being active and how that positively influences quality of life. Encourage and suggest she try new activities. Review the activity calendar to showcase the various and diverse programs. Assist her in identifying leisure time interests and discuss potential new interests. Observation and interview on 1/29/20 at 10:29 a.m. with resident 63 revealed she: Had been in bed with the lights dimmed. -The TV was on, and a book was on her bedside table. -There were no other activity books such as word search or crossword puzzles in her room. Liked to keep her door closed. Had not remembered any activity staff visiting with her. -Housekeeping staff had visited with her but no other staff. Was very lonely. Had a son and a good friend who visited occasionally. Would have liked some word search books. Review of resident 63's 1/2/20 activity evaluation revealed: She had been admitted for rehabilitation (rehab). She was confined to her bed most of the time. She required activity equipment in her room. She had enjoyed the following activities since her admission: -Computer, family contact, music, movies, puzzles, outside/fresh air, pets, singing, social situations and/or parties, and watching TV. Review of resident 63's one-on-one activities documentation for how much time had been spent with her from 12/31/19 through 1/29/20 revealed: Of the sixteen days, four days were documented at ten minutes. All other days were documented as two, three, or five minutes. Interview on 1/29/20 at 3:59 p.m. with activity director O regarding resident 63 revealed: One-on-one activities should have been done with her three to four times a week. -Those activities should have been for ten to fifteen minutes per time. When asked why some days were less than ten minutes, she stated her activities assistant would have done activities on those days. -Three minutes would not even be enough time to see if a resident had refused an activity. There were word search books available. Interview on 1/29/20 at 4:15 p.m. with director of nursing (DON) A regarding resident 63 confirmed: She had concerns with her feeling lonely and sad related to her major health challenges. Staff could have been more encouraging and visited more with her. 2. Review of resident 8's medical record revealed: She was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of resident 8's 11/1/19 MDS assessment revealed her BIMS assessment score was fourteen indicating her cognition was intact. Review of resident 8's 1/29/20 quarterly activity evaluation revealed: The activity participation summary stated the resident was provided one-on-one activities, clergy and family visits, and she listened to music or TV in her room. Activity-related problem(s) that included needs, concerns, or strengths was marked appropriate and current. Her progress toward the plan goal indicated she had met her activity goal. Review of resident 8's 9/4/19 revised activity care plan focus area revealed: The resident is dependent on staff for emotional, intellectual, physical, and social stimulation r/t (related to) physical limitations. Paints pictures, watches baseball-the Rockies, listens to country music. Review of resident 8's one-on-one activity documentation that included how much time had been spent with her from 1/1/20 through 1/29/20 revealed: One-on-one activity had been offered seventeen days for the following amount of time: -Three opportunities for two minutes. -Six opportunities for three minutes. -Two opportunities for five minutes. -Six opportunities for ten minutes. Observation and interview on 1/28/20 at 11:06 a.m. and on 1/29/20 at 10:15 a.m. with resident 8 revealed: She was lying in bed. She only left her bed for a weekly bath and enjoyed the warmth of the water. Her hands and feet were contracted, and she was often in pain. She relied on staff to meet her care needs. Her daughters visited as they were able. She no longer enjoyed watching TV or listening to the radio. -She had not followed Colorado Rockie baseball for some time. She appreciated someone sitting beside her to visit. She wanted her hair brushed more frequently because it relaxed her. She thought she might enjoy a massage with lotion. -She was not sure staff had the time to do that. She received a weekly clergy visit and liked that. Observation and interview on 1/28/20 at 4:11 p.m. with activity aide Q regarding resident 8 revealed: She provided her one-on-one activities three times per week. She usually read to or visited with the resident. An activity assessment had been completed at admission and was updated as needed when a change in activity interests and abilities occurred. 3. Review of resident 23's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. He was currently receiving hospice services. Review of resident 23's 11/12/19 MDS assessment revealed his BIMS assessment score was fifteen indicating his cognition was intact. Review of resident 23's 11/6/19 significant change activity evaluation revealed: He required a projector to enlarge printed material such as his Bible. -Having books, newspapers, and magazines was somewhat important to him. He enjoyed family contact, movies, music, sports, and woodworking. Having music he liked to listen to, pets, group activities, going outdoors, and participating in religious services were very important to him. He had the ability to play the trombone. Review of resident 23's 7/2/19 revised activity care plan focus area revealed: The resident has little or no activity involvement r/t (related to) wishes not to participate: I will be in rehab. I am independent in my day. I read my bible. I watch 700 Club, study my bible and country western movies and show. I will walk around and socialize. Review of resident 23's one-on-one activity documentation that included how much time had been spent with him from 1/1/20 through 1/29/20 revealed: One-on-one activity had been offered seventeen days for the following amounts of time: -Seven opportunities for two minutes. -Three opportunities for three minutes. -One opportunity for four minutes. -Six opportunities for ten minutes. Observation and interview on 1/28/20 at 4:15 p.m. with resident 23 revealed: He was laying in bed and said he no longer left his room. There was no TV or radio turned on. There was no adaptive activity equipment in his room. He demonstrated a sense of humor by joking. He stated his faith was important to him. His wife usually visited weekly. -She lived in a nearby town, and he hoped to transfer to a healthcare facility in the same town to be closer to her. Observation and interview on 1/28/20 at 4:35 p.m. with activity aide Q regarding resident 23 revealed: She stood at the resident's door, knocked, and said his name. She left after she had gotten no response from him. She was unaware he had a severe hearing loss. She subsequently returned to and entered his room. -She had spoken loudly enough for him to hear her ask if he needed anything. -He said no, and she responded I'll leave you alone. Interview on 1/30/20 at 8:45 a.m. with activity director O regarding resident 23's activity plan revealed: She thought he might listen to music on the TV occasionally. He used to have a projector in his room that enlarged printed material so he could read the Bible. -He no longer had that projector, and she was unsure why. She was aware religion was important to him but was not certain if clergy had visited him. They had worked on establishing a pet therapy program, but it was hit and miss. They had a music memory program, but it had not been tried with the resident. 4. Interview on 1/30/20 at 9:38 a.m. with DON A revealed it was her expectation: Activity care plans were regularly reviewed and updated. *One-on-one activity programs were individualized and meaningful to the resident. Review of the provider's 8/7/19 Activity policy revealed: It is the facility's policy to provide meaningful activity to residents.	2020-09-01
198	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	689	D	0	1	YOJP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (67) received adequate supervision to prevent falls. Findings include: 1. Review of resident 67's 1/6/20 Minimum Data Set assessment revealed: She had been admitted on [DATE]. She had multiple [DIAGNOSES REDACTED]. Her Brief Interview for Mental Status assessment score had been fifteen indicating her cognition was intact. She had been able to make her needs known. She had required the assistance of two staff members for transfers. She did not walk. She had been on a scheduled pain management plan. Her medication list had included: an [MEDICAL CONDITION] medication, an antidepressant, and an opioid pain medication. Observation and interview on 1/28/20 at 10:30 a.m. with resident 67 revealed: She had fallen in the bathroom on 1/28/20 at 9:15 a.m. -No one had seen her fall. -The certified nursing assistants (CNA) had assisted her to the toilet, and she had fallen when she tried to get up by herself. She would like to have therapy again. She did better with transfers when she had been receiving physical therapy. She would like to be able to walk again. She denied pain and no bruising was noted. She had minimal use of her left arm due to [MEDICAL CONDITION]. Interview on 1/29/20 at 3:20 p.m. with occupational therapist/director of rehabilitation G revealed: The resident had: -Not been on a restorative program. -Approached her and asked her about starting physical therapy again. She had received an e-mail on 1/28/20 late afternoon from registered nurse (RN) H with physician orders [REDACTED]. The resident had been: -Scheduled to be evaluated on 1/29/20 by the occupational therapist and on 1/30/20 by the physical therapist. -Last referred to physical and occupational therapy on 4/10/19, and she had been discharged from their caseload in (MONTH) 2019. Interview on 1/29/20 at 3:30 p.m. with RN H regarding resident 67 revealed: Falls were discussed during their morning meeting. The resident: -Had been assisted to the toilet yesterday on 1/28/20 prior to the fall. -She would have normally pulled the call light string when she was finished but yesterday she had not. -She had leaned forward into her wheelchair, lost her balance, and she fell to the floor. -She had been referred to physical and occupational therapies for evaluation for transfers, ADLs, and post fall. She had not entered a nurse's progress note regarding her fall and the subsequent physician's orders [REDACTED]. The CNAs had used the care sheets for the resident's care information. Interview on 1/29/20 at 5:15 p.m. with CNA I regarding resident 67's above fall revealed: She was on duty on 1/28/20 when the resident had fallen. She had been one of her assigned residents. She and another CNA had assisted her to the toilet. -She had placed the resident's wheelchair in front of her and put perineal (peri) cleansing wipes and gloves on the chair, per the resident's preference. -She had preferred to do her own peri-care. She had been waiting in the resident's room for her to finish on the toilet. -Another bathroom call light had sounded, and she went to assist that resident to the toilet. -She was back in resident 67's room within five minutes and found her on the floor. She had known the resident was not be be left alone on the toilet. Interview on 1/30/20 at 9:27 a.m. with director of nurses A revealed: The CNA care sheets were updated daily by RN H. Care huddles had been held daily Monday through Friday at 10:30 a.m. and 2:00 p.m. Any resident care changes from the weekend were communicated to the CNAs Monday morning. The CNAs had Kardexes in the hallways to use for residents' updates. Regarding resident 67: -She sometimes had unrealistic expectations about her abilities. -Had not liked to have the CNA in the room while she was in the bathroom. -Was no longer transferred with the stand lift. -Had been working with physical and occupational therapies and was discharged from their caseload in (MONTH) 2019. -Her care plan had not been updated to reflect she was no longer being transferred using the stand lift and assistance of two staff. -Currently had been transferred with assistance of two staff members. -Used a transfer pole with staff assistance to transfer from her bed to her wheelchair. Her expectation had been the CNAs were to follow a resident's care plan. She monitored the CNAs by walking on the units, and by talking to residents, nurses, and family members. The assistant director of nursing and unit managers had assisted her with that monitoring. Review of resident 67's care plan initiated on 4/16/19 and revised 7/31/19 revealed: Transfer: Extensive assist of one-two, standing lift. Do not leave resident alone in bathroom. She had three falls in the past month on: 12/31/19, 1/7/20, and 1/28/20. *She had used a wheelchair for mobility in the facility.	2020-09-01
199	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	693	D	0	1	YOJP11	Based on observation, interview, and policy review, the provider failed to ensure the correct procedure was followed for verification of placement of a gastrostomy feeding tube for two of four sampled residents (14 and 44) with feeding tubes by two of two licensed practical nurses (LPN) (E) and (F). Findings include: 1. Observation and interview on 1/28/20 at 11:17 a.m. with LPN [NAME] while she prepared and administered resident 14's gastric tube feeding revealed: She did not do hand hygiene when she entered the room. With her bare hands she assembled her supplies on the counter by the sink. She removed the cap from the tube feeding bag, poured in the liquid, and primed the bag. She did not wash her hands but put on gloves. Prior to connecting the tube feeding she attempted to verify the placement of it: -By instilling air into the tube. -Stated she used ten to fifteen milliliters of air directly into the tube to verify placement. -She listened with a stethoscope for that air movement over the resident's stomach and tube insertion areas. -Stated she heard the air movement. She then attempted to verify that tube placement by aspiration. -She used a sixty cubic centimeter syringe to check for residual stomach content without results. Instilled a sixty milliliter water flush. -Proceeded with the tube feeding by connecting the feeding bag to the feeding tube. Stated the above had been her usual procedure for the resident's tube feeding. 2. Observation on 1/28/20 at 9:15 a.m. during administration of resident 44's tube feeding revealed: LPN F failed to verify tube placement before she administered the water flush pre-feeding. She had correctly aspirated before starting the feeding, but had not checked the pH of gastric contents. She had checked placement after she had administered the water and said she had forgotten to do that prior to the water flush. Surveyor: 3. Interview on 1/30/20 at 1:59 p.m. with director of nurses A regarding the above revealed: Her expectation had been for LPN [NAME] to follow their tube feeding policy and agreed she had not. She stated she: -Had talked with the medical director on 1/29/20 about that policy. -He was planning to review the policy with a gastrointestinal physician. Review of the provider's (MONTH) 2019 Gastric Tube Feeding policy revealed: Procedure: -1. Place the equipment on a clean bedside stand or table. -3. Wear clean gloves. -8. Check for residual and placement by attaching a sixty (60) ml (milliliter) piston syringe to gastric tube and gently pulling back about 10 ml. --c. If no gastric content appears, the tube may be against the lining of the stomach or may be obstructed. Stop procedure and notify MD (medical doctor).	2020-09-01
200	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	697	D	0	1	YOJP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure accurate and effective pain management had been implemented for one of one sampled resident (8) reviewed for pain management. Findings include: 1. Review of resident 8's medical record revealed: She was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was receiving comfort care, and a hospice consultation had been ordered. Review of resident 8's 11/1/19 Minimum Data Set assessment revealed: Her Brief Interview for Mental Status assessment score was fourteen indicating her cognition was intact. She had experienced occasional pain. Her worst pain had been rated a nine on a pain scale of zero to ten with ten being the worst pain. Review of resident 8's revised 10/29/19 care plan goal revealed: Goal: -Resident will achieve acceptable level of pain control within one hour of medication administration through the next review date. Interventions included: -Assess pain characteristics, assist resident to a position of comfort, advise resident to request pain medication before pain becomes severe, evaluate pain medication effectiveness, monitor for non-verbal cues of pain, use non-pharmacological interventions, and medicate resident as ordered. Review of resident 8's 1/1/20 through 1/29/20 Medication Administration Record [REDACTED] Her scheduled pain medications had included: -[MEDICATION NAME] at 6:00 a.m. daily. -[MEDICATION NAME] gel applied [MEDICATION NAME] at 8:00 a.m. and 5:00 p.m. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 milligram (mg) at 6:00 a.m. and 6:00 p.m. Her as needed (PRN) pain medications had included: -Muscle rub cream to her neck, shoulders, and calf every six hours as needed. --That had not been applied during the above time frame. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, one tablet every four hours. --She had received that medication eight times during the above time frame for pain rated between two and ten. --Four times between 11:25 a.m. and 1:41 p.m. --Four times between 8:45 p.m. and 2:04 a.m. -Tylenol 325 mg, one tablet every four hours as needed for pain rated between one and three on a scale of one to ten. --She had received that medication three times during the above time frame for pain rated between three and four. --Two times between 12:01 p.m. and 1:10 p.m. --One time at 8:43 a.m. -Tylenol 325 mg, two tablets every four hours as needed for pain rated between one and three on a scale of one to ten. --She had received that medication eight times during the above time frame for pain rated between zero and eight. --Six times between the hours of 11:48 a.m. and 3:17 p.m. --Two times between the hours of 6:27 p.m. and 8:19 p.m. Observation and interview on 1/28/20 at 1:53 p.m. with resident 8 revealed: She was lying in bed. -Her hands and feet were contracted. She remained in her bed except when she was bathed each week. -It felt like too much work to get out of bed. She said she had [MEDICAL CONDITION], and her pain was all over. -She was unable to rate her pain with a number. She said her current pain management plan was not effective. -She had break through pain between the hours of 2:00 p.m. and 6:00 p.m. She said having someone to visit with and having her hair brushed was relaxing. She stated she was being evaluated for hospice services and was hopeful her pain would improve if she qualified. Observation and interview on 1/29/20 at 3:00 p.m. with resident 8 revealed: She was lying in bed. She rated her pain a six. She said she had notified staff of her pain, but she had a conflict with licensed practical nurse (LPN) J and felt she was not listened to. She re-iterated her desire for hospice to help her with pain management. Interview on 1/29/20 at 3:30 p.m. with LPN J regarding resident 8's pain revealed: Break through pain had usually occurred about 3:00 p.m. She gave the resident PRN Tylenol for that pain, because the resident had scheduled [MEDICATION NAME] at 6:00 p.m. She gave one tablet of PRN Tylenol for pain rated between one and six. She gave two tablets of PRN Tylenol for resident reported pain over six. She was aware of the personality conflict between the resident and herself. Interview on 1/29/20 at 4:45 p.m. with resident 8's primary care physician concerning her pain revealed he was unaware of mid-day break through pain concerns. Interview on 1/30/20 at 2:00 p.m. with qualified medication aide P revealed resident 8's pain had seemed to peak between 2:00 p.m. and 3:00 p.m. Interview on 1/30/20 at 2:35 p.m. with director of nursing A concerning resident 8's pain revealed she: Agreed the resident did not have adequate mid-day pain control. Was aware of the personality conflict between the resident and LPN [NAME] Stated duplicate pain scales for two separate PRN pain medications and no pain scale for another PRN pain medication should have been addressed. Expected nursing staff would have discussed their observations and the resident's reports regarding inadequate pain management with the resident's physician. Review of the provider's (MONTH) 2019 Pain Management policy revealed: Procedures: -2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Recognizing Pain: -3. Review the Medication Administration Record [REDACTED]. Monitoring and Modifying Approaches: -3. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g., approved pain scales) and relevant criteria for measuring pain management. -4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.	2020-09-01
201	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	698	E	0	1	YOJP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the provider failed to ensure: Appropriate monitoring and assessments had been completed following [MEDICAL TREATMENT] for two of three sampled residents (27 and 30) who were on [MEDICAL TREATMENT]. An ordered fluid restriction had been implemented and monitored for one of one sampled resident (30) who had been on a fluid restriction. Findings include: 1. Review of resident 27's medical record revealed: He had been admitted on [DATE]. His 1/22/20 admission Minimum Data Set (MDS) assessment revealed: -His Brief Interview for Mental Status (BIMS) score was fifteen indicating cognitively intact. -His [DIAGNOSES REDACTED]. He went to [MEDICAL TREATMENT] Monday, Wednesday, and Friday. Interview on 1/29/20 at 3:02 p.m. with licensed practical nurse (LPN) C regarding resident 27 revealed: He typically went to [MEDICAL TREATMENT] around 2:00 p.m. He returned with information from the [MEDICAL TREATMENT] center. -That information was entered on their post-[MEDICAL TREATMENT] form. She normally checked his vital signs and the shunt, monitored for any bleeding or bruising, and gave him a meal if he had not eaten at [MEDICAL TREATMENT]. She would have then document in his progress notes. Interview on 1/29/20 at 5:00 p.m. with director of nursing (DON) A regarding their process for residents who were on [MEDICAL TREATMENT] revealed: The day before the provider's [MEDICAL TREATMENT] form was completed and sent with the residents when they left for [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] center staff entered their information on the second page of that form and sent it back to the facility with the resident. -That information would then have been entered in the resident's electronic medical record. Nurses should have been completing assessments and monitoring for any change of condition following [MEDICAL TREATMENT]. Nurses should have been documenting consistently their assessments and monitoring. 2 a. Review of resident 30's medical record revealed: He had been admitted on [DATE]. His 11/27/19 significant change in status MDS assessment revealed: -His BIMS score was five indicating a severe cognitive impairment. -His [DIAGNOSES REDACTED]. He went to [MEDICAL TREATMENT] Monday, Wednesday, and Friday. Interview on 1/28/20 at 4:15 p.m. with LPN V regarding resident 30 revealed he: Typically went to [MEDICAL TREATMENT] around 2:00 p.m. Returned with information from the [MEDICAL TREATMENT] center. -That information was entered on their post-[MEDICAL TREATMENT] form. Would check vital signs and the shunt site when the resident returned from [MEDICAL TREATMENT]. Did not assess the resident's vital signs or shunt site more than when he returned to the facility. b. Review of resident 30's revised 10/2/19 care plan revealed: Focus area: Resident requires [MEDICAL TREATMENT] r/t (related to) [MEDICAL CONDITION]. Interventions included: 2000 cc (cubic centimeter) fluid restrictions. Continued review of resident 30's medical record revealed an order that stated: Per [MEDICAL TREATMENT]: 2000 cc fluid restriction per 24 hours every shift related to END STAGE [MEDICAL CONDITION]. Review of resident 30's following fluid intake records revealed: Seven times in (MONTH) 2019 his fluid intake had been greater than 2000 cc in twenty-four hours. Four times in (MONTH) 2019 his fluid intake had been greater that 2000 cc in twenty-four hours. Five times from (MONTH) 1 through 28, 2020 his fluid intake had been greater than 2000 cc per twenty-four hours. Interview on 1/28/20 at 4:15 p.m. with LPN V regarding resident 30 revealed he: Looked at what the resident drank for breakfast and lunch and recorded that amount for his daytime fluid intake. Used the liquids the resident was served at meal time to administer his medications. Had been unaware of any other fluid restriction monitoring for the resident. Had been unsure if there was a specific amount of fluid the resident was allowed in his room on the day shift. Stated the resident got cups of ice from the ice machine himself. Interview on 1/28/20 at 4:00 p.m. with certified dietary manager W regarding resident 30 revealed: She had a computer program she entered the resident's fluid restriction in. The program told her how much fluid she had per meal for the resident. She then reported that amount to nursing, and they would use the remaining amount for in-room fluids and medication passes. Interview on 1/29/20 at 8:30 a.m. with DON A revealed there had not been a process in place to monitor any fluid restrictions for resident 30. 3. Review of the provider's (MONTH) 2019 [MEDICAL TREATMENT] Management policy revealed: The facility had designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of [MEDICAL TREATMENT] residents. Assess and manage post [MEDICAL TREATMENT] complications which may include, but are not limited to fever, headache, nausea, vomiting, back pain, dementia, [MEDICATION NAME], [MEDICAL CONDITION], hypertension, cardiac arrhythmia, air [MEDICAL CONDITION], hemorrhage, metabolic problems, [MEDICAL CONDITION], muscle cramps, restlessness, and [MEDICAL CONDITION]. Maintain fluid restrictions, as ordered. Record intake if fluid restriction ordered. Review of the provider's (MONTH) 2019 Hydration policy revealed: It is the facility's policy to ensure that residents were adequately hydrated and to ensure fluid restrictions are followed as ordered. Those with physician orders [REDACTED]. The amount of fluids given by nursing will be recorded in the medical record.	2020-09-01

CMS-Nursing-Home-Full-Deficiencies

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