cms_AK
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 166 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure: 1) prompt efforts to resolve 2 residents (#s 3 and 4) concerns over lost clothing that was laundered at the facility, 2) prompt efforts to resolve a resident's (#9) concerns related to activities and lost items, and 3) residents (based on a census of 25) knew how to file a grievance with the grievance officer. Failure to ensure complaints and grievances were resolved and residents had access to accurate information on how to file a grievance, placed residents at risk for not having their concerns addressed in a timely manner. Findings: Missing clothing Resident #3 Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. During a group interview on 5/17/17 from 9:00 am - 9:50 am, Resident #3 stated he/she had a white dress shirt that went missing. The Resident stated the facility knew the shirt was missing and had looked for it. The item had not been found or replaced. Resident #4 Record review from 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. During a group interview on 5/17/17 from 9:00 am - 9:50 am, Resident #4 stated he/she lost a pair of black pants. The Resident stated the pants went missing around 6 months ago and said at this point they will never show up. The Resident further stated the facility did not offer to replace the pants and told the Resident to make sure the clothing is labeled. During an interview on 5/19/17 at 10:00 am the Activities Staff (AS) #2 stated the facility tried their best to find missing clothing, but we are not responsible (for missing clothing). Additionally, on 5/19/17 at 9:30 am, the facility provided a form titled Lost Item Report. The Charge Nurse (CN) stated activities staff kept track of the missing items using the lost item report form. The CN further stated the facility was only responsible to replace lost medical equipment. Dur… | 2020-09-01 |
| 2 | 2 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 241 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide cares and services in a manner that maintained and promoted dignity for 3 residents (#'s 5, 14 and 15). Specifically, the facility failed to: 1) ensure personal care was provided in a manner to promote dignity and comfort for 1 resident (#5) out of 5 residents observed during personal cares, and 2) removed gait belts (devices used by caregivers to transfer residents with mobility issues from one position to another, from one location to another or while ambulating residents who have problems with balance) for 2 residents (#'s 14 and 15) out of 5 observed during a group meeting who required gait belt use for transfers. These failed practices had the potential to negatively affect the residents' self-esteem and quality of life. Findings: Personal Cares: Resident #5 Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, [MEDICAL CONDITION], recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as needing extensive assistance with 2 persons for bed mobility, dressing and personal hygiene. Observation on 5/16/17 at 11:18 am, revealed certified nursing assistants (CNA) #s 1 and 2 provided morning cares to Resident #5. During cares, CNA #2 rolled the Resident to the left side exposing his/her buttocks and genitals. During the observation CNA #2 left the bedside multiple times to obtain various items such as clothing, mechanical lift and sling. The CNAs did not cover the Resident while CNA #2 left to get supplies. As a result, the Resident was exposed while waiting for staff to obtain supplies. Observation on 5/16/17 at 12:27 pm revealed CNA#s 1 and 3 were dressing Resident #5. During the observation both CNAs raised Resident #5's legs off the bed approximately… | 2020-09-01 |
| 3 | 3 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 242 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 2 residents (#s 7 and 9) out of 10 sampled residents were provided the opportunity to make choices significant to them and consistent with his or her interests and plan of care. Specifically, the facility failed to provide opportunities for: 1) Resident #7 to sit in the recliner in the activities room, and 2) Resident #9 to do activities such as arts and crafts, in his/her room. This failed practice had the potential to affect the residents' quality of life in general. Findings: Resident #7 Record review from 5/16-18/17 revealed the [AGE] year-old Resident was admitted to the facility with [DIAGNOSES REDACTED]. The Resident had a Personal Representative (PR) to assist in making health care decisions for him/her. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as total dependence for transfers. Additionally, the Resident was coded as having short and long-term memory problems and was moderately impaired (decisions poor; cues/supervision required) for cognitive skills for daily decision making. Review of the comprehensive care plan revealed the Problem: Alteration in cognition .Goal: Resident will be able to function to their highest level, as is compatible with their current cognition .Intervention: Offer resident choice (where to sit .) . Random observations from 5/15-18/17 revealed Resident #7 was sitting in the wheelchair for the lunch time meal and remained up until after dinner. During the observations facility staff did not offer the Resident an opportunity to relax in the recliner or other alternative seating. During an interview on 5/18/17 at 11:40 am, Resident #7's PR stated he/she would like to see the Resident in the recliner in the activity room more often. The PR stated the Resident was up in the wheelchair for a long time and sometimes fell asleep in the wheelchair. Res… | 2020-09-01 |
| 4 | 4 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 278 | E | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure MDS (Minimal Data Set), a Federally required nursing assessment, were accurately completed to reflect the status of 3 residents (#s 4, 5 and 6) out of 6 residents who's MDS's were reviewed. This failed practice resulted in inaccurate information about 3 residents and placed them at risk for inaccurate care planning and care. Findings: Resident #4 Record review from 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of Resident #4's Medication Administration Record [REDACTED]. Review of the discontinued and completed medication lists from 10/16/16 to 5/18/17 revealed no antipsychotic medications were listed. Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE], revealed the assessment coded the Resident as receiving antipsychotic medications during the last 7 days. During an interview on 5/17/17 at 2:30 pm the MDS Coordinator stated Resident #4 had not taken any antipsychotics should not have been coded as taking them on the 2/15/17 MDS assessment. Resident #5: Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, [MEDICAL CONDITION], depression, recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Initial/Admission Assessment: Review of the MDS assessment, an admission assessment, dated 2/14/17, revealed the Resident was coded as dressing did not occur under the activities of daily living (ADLs). In addition, the Resident was coded as having an unstageable pressure ulcer that was not present on admission and taking antipsychotic medication during assessment period. During an interview on 5/17/17 at 1:34 pm the MDS Coordinator stated the ADL dressing did occur and it was a miscoding. The MDS Coordinator further stated the Resident did have a pressure ulcer on admission and the MDS was miscoded. The MDS Coord… | 2020-09-01 |
| 5 | 5 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 280 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to update and revise the care plan to reflect the current level of care and services for 1 resident (#3) out of 7 residents whose care plans were reviewed. Specifically, the facility failed to revise a care plan to reflect the need for a gait belt when the resident was out of bed. Failure to assess and revise care plan problems, goals, and interventions placed the resident at risk for not receiving appropriate and/or necessary care and services. Findings: Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED].) and frequent falls. Review of the comprehensive care plan, dated 4/26/17, revealed .Use assistive device when assisting with transfers and ambulation .1 person stand by assist with gait belt and FWW (front wheeled walker) Random observations throughout the survey from 5/15-19/17 revealed the resident had a gait belt on his waist while he/she sat in his/her wheelchair. During an interview on 5/16/17 at 8:50 am certified nursing assistant (CNA) #5 stated, We keep (his/her) gait belt on when (he/she) is out of bed, just in case (he/she) is impulsive and rises on (his/her) own. Observation during Resident group meeting on 5/16/17 from 9:00 am to 9:50 am revealed Res #3 left the meeting briefly. On his/her return at 9:25 am, he/she wore a gait belt. Res #3 stated have to leave gait belt on all the time so they can grab you I guess. The facility did not provide a policy for care plans as requested. | 2020-09-01 |
| 6 | 6 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 314 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation and policy review, the facility failed to: 1) prevent a pressure injury, and 2) follow treatment interventions for a pressure injury. Specifically, the facility failed to implement preventative measures in a timely manner and failed to provide the necessary treatment for [REDACTED].#5) out of 6 sampled residents who were identified by the facility for at risk for pressure injuries. This failed practice caused the resident to obtain an avoidable pressure injury and delayed treatment which resulted in pain with an increased risk for infection, delayed healing, and poor medical outcome. Findings: Resident #5 Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive, recurrent skin integrity issues, diabetes, stroke and flaccidity to left side of body. Further review revealed, the Resident had a pressure injury on the left heel on admission. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed the Resident was coded as: 1) Being at risk for pressure ulcers; and 2) Had an unhealed unstageable (slough/eschar) pressure ulcer on the left heel. Further review of the admission MDS revealed the Resident coded as the following under Activities of Daily Living (ADLs): 1) Extensive assist with two staff during bed mobility and transfer. 2) Supervision with locomotion on the unit; and 3) Total assistance with bathing and hygiene. Review of the medical record revealed Resident #5 had a new pressure injury to the right heel, identified on 4/27/17. The pressure injury was staged as - Unstageable .Yellow; Brown; Eschar . Review of the most recent MDS quarterly assessment, dated 5/9/17, revealed the Resident was at risk for pressure ulcers and had two unhealed pressure ulcers: an unstageable deep tissue ulcer to the left heel and a new unstageable (slough/eschar) ulcer to the right heel. Further review revealed the Resident's required assistance… | 2020-09-01 |
| 7 | 7 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 332 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 2 residents (#s 12 and 13), out of 5 residents observed during medication administration, received medications per physician's orders [REDACTED].#12) was given a medication without measuring blood pressure prior to administration per physician's orders [REDACTED].#13) was given a medication that was administered contrary to manufacturer recommendation and physician order, specifically crushed vs. whole. This failed practice placed the facility's medication error rate above 5% and placed the resident at risk for not receiving therapeutic benefits from the medications. Findings: Resident #12 Record review on 5/16-18/17 revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review on 5/16/17 revealed Resident #12's medication regime included the Resident had an order for [REDACTED]. Observation during a medication pass on 5/16/17 at 12:00 noon, revealed LN #2 entered Resident #12's blood pressure results in the Medication Administration Record [REDACTED]. During an interview on 5/16/17 at 12:00 noon, licensed nurse (LN) #2 stated he/she only takes Resident #12's blood pressure in the morning and the afternoon. The LN further stated Resident #12's blood pressure was always high. During an interview on 5/18/17 at 8:30 am, LN #3 reviewed the order and stated Resident #12's blood pressure should be taken prior to giving [MEDICATION NAME]. During an interview on 5/17/17 at 3:30 pm, Pharmacist (PH) #2 stated the blood pressure should be taken within 1 hour of giving the blood pressure medication [MEDICATION NAME]. He/she further stated the blood pressure reading from the prior dose should not be used for the current dose. Resident #13 Record review on 5/16-19/17 revealed Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 5/18/17 revealed Resident #13's medication regime included Aspirin EC ([MEDICATION NAME] coated… | 2020-09-01 |
| 8 | 8 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 492 | D | 0 | 1 | YBQY11 | Based on observation, document review and interview the facility failed to ensure blood glucose testing competencies for 16 active certified nursing assistants (CNAs) out of 18 reviewed were conducted in compliance with Alaska Nursing Statutes and Regulations. This failed practice placed 4 residents (#s 2, 5, 9 and 12) out of 14 active residents who required blood glucose monitoring, at risk for improper technique of obtaining blood glucose. This failed practice had the potential for complications such as infection or inaccurate reading. Findings: Random observations from 5/15-17/17 revealed various CNAs completing blood glucose testing on residents. Review on 5/17/17 at 3:47 pm of the CNA Glucometer Competency packet, last updated 4/2017, revealed the following: - CNA #s 1, 10, 12, 13 and 14 had no initial competency or 90-day evaluation; - CNA #s 2, 3, 4, 5, 6, 7, 9, 15 and 16 did not have a 90-day evaluation completed; and - CNA #s 8 and 11 90-day evaluations were completed late. During an interview on 5/17/17 at 3:47 pm the Charge Nurse (CN) stated it was his responsibility to complete the CNA glucometer competencies. The CN confirmed some competencies had been either late or not completed. Review of the Alaska Nursing Statues and Regulations, dated 9/2016, revealed 12 AAC 44.960 .Specialized nursing duties may be delegated to another person under the standards set out in 12 AAC 44.950. (b) Specialized nursing task that may be delegated include .(3) obtaining blood glucose levels .(8) A nurse who delegates a nursing duty to another person under this section shall develop a nursing delegation person. The delegating nurse shall evaluate a continuing delegation as appropriate, but must perform an evaluation of the performance of the delegated duty by the other person. The delegating nurse shall evaluate the continuing delegation as appropriate, but must perform an evaluation on-site at least every 90 days after the delegation was made. The delegating nurse shall keep a record of the evaluations conducted. | 2020-09-01 |
| 9 | 9 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 514 | E | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to maintain accurate and complete medical records. Specifically, the facility failed to: 1) document the indication of use for medications in the residents' medical record for 4 residents (#s 1; 3; 4 and 10) out of 10 sampled residents whose medical records were reviewed, and 2) accurately document the current medical treatment (saline lock flush and pain medication) for 1 resident (#5) out of 7 sampled residents. These failed practices placed the residents at risk for not receiving services needed to address medical conditions. Findings: Indications for Use of Medications: Resident #1 Record review from 5/16-19/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the current medication administration record (MAR) and medication order detail revealed no documentation of [DIAGNOSES REDACTED]. Resident #3 Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED].) and frequent falls. Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #4 Record review on 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed Resident #4's medication regime included: 1) Atorvastatin ([MEDICATION NAME]) - used to treat high cholesterol 2) [MEDICATION NAME] ([MEDICATION NAME]) - an antidepressant 3) [MEDICATION NAME] ([MEDICATION NAME]) - an antidepressant 4) [MEDICATION NAME] ([MEDICATION NAME]) - a diuretic Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #10 Record review on 5/18-19/17 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of Resident #10's medication regime revealed Resident #10 was taking the antipsychotic medication [MEDICATION NAME] 10 mg nightly. Review of the curren… | 2020-09-01 |
| 10 | 10 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-06-10 | 600 | D | 1 | 0 | TIZ611 | > Based on record review and interviews the facility failed to ensure 1 resident (#3) out of 4 sampled residents was protected from verbally and physically assaultive behavior by staff. This failed practice placed the resident at risk for psychosocial and physical harm from abusive staff behaviors. The facility had implemented corrections prior to the investigation. Findings: Record review on 6/7/19 revealed Resident #3 had a disorder that resulted in dementia, mood disorders, and uncoordinated muscle movements. The Resident was one of several residents on the unit on enhanced observation (individual staff that monitored the resident one to one, due to a high fall risk). Review of the report provided to the State Agency on 6/3/19 revealed on 5/30/19 at approximately 7:30 pm, Licensed Practical Nurse (LPN) #1, who had been assigned to provide enhanced observation of the Resident, was to be heard 'screaming' at the Resident and telling (him/her) couldn't come out of (his/her) room. (LPN #1) was further noted to be yanking at the Resident's shirt attempting to pull (him/her) back in the bed, by force. Further review revealed Certified Nursing Assistant (CNA) #s 1 and 2 interceded, redirected the Resident, and reported the event to the Registered Nurse (RN) that was in charge on 5/30/19. The RN assessed the Resident, administered his/her evening medications and assisted the Resident back to (his/her) room. The Resident did choose to have (LPN #1) remain sitting with (him/her) rather than a new and unknown CNA floated from outside the unit. LPN #1 continued to provide enhanced observation of the Resident the remainder of the night. During an interview on 6/6/19 at 8:30 pm, LPN #2 stated he/she had been left out of the loop. The LPN stated the evening of 5/30/19, the CNAs had mentioned there had been a confrontation, as Resident #3 is normally very vocal, LPN #2 stated he/she planned to address it when after he/she finished passing medications. The LPN stated when he/she checked the Resident was sleeping and LPN #1 was… | 2020-09-01 |
| 11 | 11 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 578 | E | 0 | 1 | RHGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to 1) have a written Advanced Directives (AD) policy and 2) ensure evidence AD information was provided for 5 residents (#s 2; 3; 7; 12 and 14) out of 14 sampled residents. This failed practice had the potential to deny the residents the right to choose and make end of life medical care decisions. Findings: Resident #2 Record review on 7/30/18 - 8/3/18 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set - a Federally required assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #2 has a BIMS (Brief Interview for Mental Status) score of 15 (a score of 13-15 means the person is cognitively intact). Review of Resident #2's medical record revealed an incomplete AD. Resident #2 only had 2 pages of a 9 page packet entitled Five Wishes: Page 2 of the packet, Wish 1, and page 8, Signing the Five Wishes Form. Further review revealed no documentation that Resident #2 had completed an AD or was offered assistance to formulate an AD. Resident #3 Record review on 7/30/18 - 8/3/18 revealed Resident #3 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a quarterly assessment dated [DATE], revealed Resident #3 had a BIMS score of 0 (a score of 0-7 means the person is severely impaired). Review of Resident #3's medical record revealed no AD. A Power of Attorney was present. Further review revealed no documentation that Resident #3's guardian was asked if Resident # 3 had an AD or offered assistance to make one if desired. Resident #7 Record review on 7/30/18 - 8/3/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a significant change dated 5/28/18 revealed Resident #7 had a BIMS score of 15. Review of Resident #7s electronic medical record revealed no AD. When asked for the residents AD,… | 2020-09-01 |
| 12 | 12 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 657 | E | 0 | 1 | RHGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to update and revise the care plan to reflect the current level of care and services for 3 residents (#s 3, 14, 16) out of 14 sampled residents. Failure to assess and revise care plan problems, goals, and interventions placed the residents at risk for not receiving appropriate and/or necessary care and services. Findings: Resident #3 Record review on [DATE] - [DATE] revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #3's most recent care plan, undated, revealed 18 Multidisciplinary Problems (Active). The expected end date, or target date, for all of these identified problems expired on [DATE]. Review of the most recent MDS (Minimum Data Set - a federally required nursing assessment) assessment revealed a quarterly assessment was completed on [DATE] preceeding the expired dates on the careplan. Review of the Quarterly Team Conference, dated [DATE], revealed the team reviewed the current care plan for all identified problems and approaches. Resident #14 Record review on [DATE] - [DATE] revealed Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an annual assessment dated [DATE], revealed Resident #14 required extensive assistance in bed mobility, locomotion on and off unit, toileting, and dressing. He/she was coded total dependence for transfers and personal hygiene. Review of Resident #14's care plan revealed a Problem: Impaired strength and/or mobility . dated [DATE] and a Description: Related to left side [MEDICAL CONDITION] and [MEDICAL CONDITION] post [MEDICAL CONDITION]. Interventions for this problem were documented as restorative aid, range of motion exercises, with the goal needs to maintain current flexibility and prevent contractures. Further review of Resident #14's medical record revealed Occupational Therapy (OT) added instructions for a palm protector with finger separ… | 2020-09-01 |
| 13 | 13 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 684 | D | 0 | 1 | RHGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to provide nail care for a fungal infection that may have contributed to major nail deformity and discomfort for 1 resident (#14) out of 14 sampled residents. This failed practice placed the resident at risk for actual decline in physical, mental, and/or psychosocial well-being. Findings: Record review on 7/30/18 - 8/3/18 revealed Resident #14 was admitted to the facility with a [DIAGNOSES REDACTED]. During an interview on 7/31/18 at 11:57 am, Resident #14 and his/her spouse stated there was a need for nail care due to a fungal infection. The spouse stated they have not been able to see a nail doctor and he/she has requested assistance to get Resident #14 to a nail doctor from staff, but it hasn't happened. Resident #14 further states his/her nails hurt all the time, and they embarrass him/her, they make me feel like a witch, and he/she hides his/her hand under blankets. An observation on 7/31/18 at 11:57 am, revealed two nails (middle and ring finger) on Resident #14's left hand that were deformed, growing out and almost perpendicular to the nail bed. The nails themselves were extremely thick and overgrown, pushing into the nail bed of the finger. During an interview on 8/1/18 at 1:44 pm, the Infection Preventionist and Director of Nursing stated the charge nurse has been trying to get Resident #14 a podiatry (foot doctor) appointment with a traveling podiatrist. The facility could not provide documentation that a nail appointment is pending for Resident #14. During an interview on 8/3/18 at 11:19 am, the Social Worker indicated that they are not involved in making medical appointments. Review of Quarterly Team Conference notes, dated 10/27/17, 1/23/18, and 4/12/18, revealed no documentation of the need for nail care or any steps taken to get a podiatry consult made. Review of Resident #14's Care Plan revealed Problem: Health Promotion, start date 6/1/18: - Appointment wi… | 2020-09-01 |
| 14 | 14 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 689 | E | 0 | 1 | RHGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the adequate supervision for 1 resident (#7) out of 14 sampled residents. Specifically, the facility failed to conduct a safety assessment on one resident (#7) utilizing a wheelchair to leave the facility. This finding places the resident at a potential risk for an accident. Findings: Resident #7 Record review on 7/30/18 - 8/3/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Observation on 7/31/18 at 7:00 am, revealed the Resident outside the facility in a wheelchair. The Resident was observed stationary in a wheelchair on the sidewalk at the top of a steep incline needing to be navigated in order to gain access to the facility. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a significant change assessment dated [DATE], revealed Resident #7 had a BIMS (Brief Interview for Mental Status) score of 15 (a score of 13-15 means the person is cognitively intact). Further review revealed the significant change MDS assessment dated [DATE] was a result of the resident experiencing a fracture from a fall. During an interview on 8/2/18 at 15:35 pm, the Director of Nursing (DON) and Administrator (ADM) both stated no, when asked if the Resident had a safety assessment based on observations of the Resident behaviors. Additionally the DON and ADM stated no when asked if the facility had a policy for safety assessments for residents leaving the facility in wheelchairs. | 2020-09-01 |
| 15 | 15 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 755 | F | 0 | 1 | RHGS11 | Based on observation and interview the facility failed to have consistent safeguards in place for appropriate disposition of controlled substance medications within the medication storage room. Specifically, the Cactus Smart Sink (a secured, closed cartridge for controlled substance medication disposal) was overfull with disposed medication to the point the medications were accessible. This failed practice had the potential to affect all residents (based on a census of 18), disrupt facility reconciliation of disposed controlled substance medication and/or cause potential loss, diversion, or accidental exposure. Findings: During an observation of the medication storage room on 8/2/18 at 9:45 am, it was noted the Cactus Smart Sink was overfull. Multiple pills and powder were visible and accessible by hand. It was further observed that the red light was blinking on the Smart Sink system. During an interview on 8/2/18 at 10:10 am, Pharmacist #1 stated when the red light blinks on the Cactus Smart Sink it needs to be emptied. During an interview on 8/2/18 at 10:20 am, Pharmacy Tech #1 visualized the Cactus Smart Sink in the medication storage room and stated the cartridge was overfull. He/she further stated the pills and powder should not be visible within the sink. During an interview on 8/2/18 at 10:30 am, Licensed Nurse (LN) #4 stated when the red light blinks, it means the cartridge within the Cactus Smart Sink need to be changed because it is full. LN #4 had not called the pharmacy for them to replace the cartridge prior to this observation. Review of facility's policy Cactus Smart Sink Use Policy, dated 3/9/18, revealed: Cactus Smart Sink: Cactus Smart Sink is a secure pharmaceutical waste container that accepts the disposal of solids and liquids converting them into an unusable and unrecoverable state. Further review revealed: When a cartridge is full, the unit will notify the pharmacy to replace it. | 2020-09-01 |
| 16 | 16 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 758 | D | 0 | 1 | RHGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure 1) PRN (as needed) [MEDICAL CONDITION] (any drug capable of affecting the mind, emotions, and behavior) medication was limited to a 14 day duration in compliance with federal regulation and 2) was re-evaluated by a physician with appropriate documentation for continued use in 2 residents (#5 & #14), out of 6 sampled residents. This failed practice placed the residents at risk for receiving unnecessary medication and for experiencing potentially severe and debilitating side effects of [MEDICAL CONDITION] medication. Findings: Resident #5 Record review on 8/1/18 of Resident #5 most recent MDS (Minimum Data Set-a federally required nursing assessment), a significant change assessment dated [DATE], revealed [DIAGNOSES REDACTED]. Review of Resident #5's Medication Administration Record [REDACTED]. Further review revealed this medication started on 11/29/17 with an end date of 11/29/18 (a 1 year order). [MEDICATION NAME] is a medication used to relieve anxiety. Review of Resident #5's medication administration history revealed the following PRN use for anxiety: - (MONTH) (YEAR): 5 doses received - (MONTH) (YEAR): 8 doses received - (MONTH) (YEAR): 5 doses received - (MONTH) (YEAR): 5 doses received - (MONTH) (YEAR): 6 doses received - (MONTH) (YEAR): 3 doses received - (MONTH) (YEAR): 2 doses received Additional review of the MAR indicated [REDACTED]. Review of the physician's notes, dated 12/1/17, 2/5/18, 4/2/18, and 6/4/18, revealed no documentation of the number of times [MEDICATION NAME] PRN was used, or the efficacy of the [MEDICATION NAME] PRN use. Further review revealed no documentation of a possible dosage reduction or projected duration of [MEDICATION NAME] PRN use. Review of the Pharmacist's 30 day Drug Regimen Reviews, dates (MONTH) (YEAR) through (MONTH) (YEAR), revealed no recommendation on the [MEDICATION NAME] PRN use, nor any recommendation to attemp… | 2020-09-01 |
| 17 | 17 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 812 | F | 0 | 1 | RHGS11 | Based on observation, interview, and record review of the central kitchen area, the facility failed to prepare food under proper sanitation and food handling practices. Specifically, the food service staff failed to perform hand hygiene according to accepted professional practices during the provision of food care and services. This failed practice placed all residents (based on a census of 18) at risk for the development of disease and infection in a vulnerable population. Findings: Observation on 7/30/18 at 16:40 pm, revealed Kitchen Staff (KS) #s 2 & 3 preparing meal trays for the long term care residents. Continual observations revealed KS #3 not performing hand hygiene between glove changes during tray assembly. The assembly of the meal trays included handling the food with gloved hands. Observations further revealed KS #2 with gloves on, going to the freezer, opening the door and pulling out a loaf of frozen bread. KS #2 continued to open the bag, reach in, break the loaf apart and grab a piece of bread from the middle of the loaf. KS #2 then put the piece of bread in toaster and continued back to the tray line to assemble meals without glove changes or hand hygiene. During an interview on 8/3/18 at 7:20 am, KS #4 stated yes when asked if hand hygiene should be performed between glove changes. During an interview on 8/3/18 at 10:05 am, the Dietary Manger stated yes when asked if hand hygiene should be performed between glove changes. Review of the facility policy Washing Hands-Ketchikan Medical Center Food Service Department - SOP, undated, revealed 7. Wash Hands: Before putting on or taking off gloves. Review of the State of Alaska, Department of Environmental Conservation, Alaska Safe Food Worker Handbook accessed 8/6/18 at https://dec.alaska.gov/eh/fss/training.html, revealed Part 1: Food Worker Knowledge and Health, Handwashing, When to Wash your Hands .When changing gloves. | 2020-09-01 |
| 18 | 18 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 842 | D | 0 | 1 | RHGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident information was accurately documented for 3 residents (#s 2, 3, 14) of 14 sampled residents. This failed practice placed the residents at risk for not receiving services needed to address medical conditions. Findings: Resident #2 Record review on 7/30/18 - 8/3/18 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #2's most recent care plan, undated, revealed 13 Multidisciplinary Problems (Active). Additional review of the individual problems revealed the following omission and/or discrepancies: 1) Review of the Problem: Difficulty swallowing . revealed no start date to the problem or the 4 interventions. 2) Review of the Problem: Alterations in comfort . revealed a start date of 4/26/17. This problem describes a cervical fracture that occurred on 4/8/18 (start date is almost one year before incident occurred). All 8 interventions to this problem also have a start date of 4/26/17. Resident #3 Record review on 7/30/18 - 8/3/18 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #3's care plan, undated, revealed 18 Multidisciplinary Problems (Active). Additional review of the individual problems revealed the following discrepancy: 1) Review of the Problem: Elevated A1C . (A blood test that reflects your average blood glucose levels over the past 3 months) revealed a start date of 5/10/16 and an expected end of 5/14/18. Two interventions to this problem are 1) Monitor resident's blood sugars as ordered and 2) Monitor A1c level as ordered. During an interview on 8/3/18 at 11:20 am, Licensed Nurse (LN) #4 stated there are no current orders for blood sugar or A1C monitoring. The last blood sugar on Resident #3 was 2/22/16. The last A1C drawn was 7/17/15. Resident #14 Record review on 7/30/18 - 8/3/18 revealed Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. Review of … | 2020-09-01 |
| 19 | 19 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 880 | D | 0 | 1 | RHGS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure staff performed hand hygiene according to accepted professional practices during the provision of care and services for 1 resident (#4) out of 14 sampled residents. This failed practice increased the risk for the development and transmission of disease and infection in a vulnerable population. Findings: Record review on 7/30/18 - 8/3/18 revealed Resident #4 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #4 most recent MDS (Minimum Data Set-a federally required nursing assessment), a quarterly assessment dated [DATE], revealed he/she was assessed as totally dependent on staff assistance to eat. During an observation on 7/30/18 at 5:20 pm, Certified Nursing Assistant (CNA) #2 prepared to assist Resident #4 with dinner. The CNA entered the room, washed his/her hands, and donned a pair of gloves. Further observation revealed CNA #2 then went to the bedside picked up a safety mat off the floor, folded it, and placed it against the wall. With the same gloves on, CNA #2 then positioned the Resident's head of bed up and positioned Resident #4 for eating dinner. Further observation revealed CNA #2 positioned Resident #4's food tray on the bedside table and began handling the food and food items without changing the gloves he/she had used to handle the floor mat. CNA #2 mixed all of Resident #4 pureed food together as well as prepared the rest of the tray before he/she changed gloves to assist Resident #4 to eat dinner. During an interview on 7/30/18 at 5:32 pm, CNA #2 stated he/she should have changed gloves and completed hand hygiene prior to making contact with the Resident #4's bed and before preparing his/her food. Review of the facility's competency training Your 5 Moments for Hand Hygiene, no date, revealed: clean your hands after touching a patient and her/his immediate surroundings . Review of the facility's competency training verifi… | 2020-09-01 |
| 20 | 20 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2018-08-03 | 908 | F | 0 | 1 | RHGS11 | Based on observation and interview the facility failed to ensure patient care equipment was maintained in safe operating condition. Specifically, the plate warmer in the kitchen, SECO model 66 lacked a preventive maintenance or inventory sticker placing all residents (based on a census of 18) at risk for receiving foods at inconsistent and/or potentially dangerous temperature ranges. Findings: Observations on 7/30 - 8/3/2018 revealed kitchen staff retrieving plates from a SECO model 66 plate warmer. Further observation revealed the equipment lacked a preventive or any type of maintenance or inventory sticker. During an interview on 8/1/18 at 12:25 pm with the Dietary Manager (DM) when asked how maintenance on the plate warmer was completed, the DM reported when the machine breaks we submit a work order and it gets fixed. When asked to see the policy for maintenance/use and owner's manual for the plate warmer the DM was unable to produce these documents. During an interview on 8/1/18 at 2:30 pm with Environmental Services (ES) employee #s 1 and 2, when asked to produce a policy or any documentation for maintenance/use or the owner's manual for the plate warmer they were unable to produce these documents. | 2020-09-01 |
| 21 | 21 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 550 | D | 1 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, document review, interview, and state statute review, the facility failed to ensure that the rights of a resident with a guardian were exercised to the extent provided by state law. Specifically, the facility failed ensure 1 resident (#1) out of 4 residents reviewed, code status accurately reflected his/her wishes to be comfortable at the end of his/her life and conflicting views were resolved prior to the resident's death. This failed practice placed the resident at risk for pain and suffering from futile traumatic medical treatment. Findings: Record review 8/22-23/19 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's most recent MDS (Minimum Data Set- A federally mandated nursing assessment) dated 5/20/19 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 15, which indicated no impairment to Resident #1's attentiveness, orientation to person, place, time and situation, and ability to recall events. Record review of POLST (Physicians Orders for Life Sustaining Treatment) dated 3/7/18 revealed that Resident #1 was made a DNR (do not resuscitate). The document was signed by a public guardian. Resident #1 did not sign the document. Review of ethicist note dated 6/5/19 revealed, (Physician #1) spoke to me about the patient's disposition and Code Status. (Resident #1) . admitted to our LTCU (long term care unit) .with multiple medical and behavioral challenges which necessitated the state of Alaska appointing a public guardian through the office of Public Advocacy. (Resident #1's) guardian has the right and responsibility to ensure (his/her) financial, legal, and medical concerns are addressed, and while the courts have declared (him/her) no longer capable of making these decisions, a guardians role is to ensure the patient's wishes are taken into consideration. There has been considerable confusion regarding Code Status based on a POLST document compl… | 2020-09-01 |
| 22 | 22 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 585 | F | 0 | 1 | 0OWF11 | Based on observation, interview, and policy review, the facility failed to: 1) follow the grievance policy on patient care issues, 2) clearly inform residents and/or their families of the process for filing an anonymous grievance, and 3) provide correct information to contact external agencies. This failed practice had the potential to affect all residents of the facility, based on a census of 21, to deny their right to have their grievances investigated with the potential to compromise the quality of care provided by the facility. Findings: An observation on 8/19/19 at 2:54 pm, revealed no grievance box or forms were visible in the common areas. During an interview on 8/21/19 at 11:06 am with the Resident Council, Resident #'s 3, 4, 10, 12, 15, and 174 did not know who the Grievance Officer (GO) was, or where to find the contact information. Resident #16 knew the information was posted in the common area. Residents further stated they did not know how to file a grievance and stated they would talk to the nurses if they had a problem. During an interview on 8/21/19 at 11:32 am, Resident #16 stated that with high nursing turnover, he/she was not always sure who the best staff to ask was when issues came up. During an interview on 8/21/19 at 2:03 pm, Resident #6 stated that he/she had not submitted any grievances and further stated he/she felt it would fall on deaf ears. Resident #6 stated he/she thought the grievance process was sending a letter to the ombudsman and/or state agency. During an interview on 8/21/19 at 3:31 pm, the GO stated he/she did not come to the unit to see the Residents. There was no box or forms available on the unit. He/she was asked by the Activities Coordinator (who arranged the Resident Council meetings) to attend and meet the Residents. The GO stated he/she had attended one meeting since January. The GO stated that grievances could be submitted by phone, through contact with the Director of Nurses, or through variance (incident) reports. When asked how a Resident would file an anonymous … | 2020-09-01 |
| 23 | 23 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 600 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure that a resident was from free from racially directed verbal abuse by another resident for 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause the resident to experience humiliation, shame and/or degradation. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 8/21/19 at 8:14 am, Resident #6 stated that another Resident of the facility had used racially biased language directed at him/her. Resident #6 further stated that staff blew off Resident #6's concerns by making excuses for the other Resident. Resident #6 identified a single Resident as the perpetrator of the verbal abuse and stated that staff had not done anything to address the abuse or prevent it from re-occurring. Resident #6 stated that he/she was directed to avoid the perpetrator or go to his/her room if the perpetrator was present in the common areas. Resident #6 stated he/she felt insulted and abused by the racial verbal abuse and was angry that staff did not make efforts to address the abuse. During an interview on 8/21/19 at 10:00 am, Licensed Nurse (LN) #4 stated that he/she had heard of altercations between Resident #6 and the alleged perpetrator. LN #4 stated that re-direction was given to the perpetrator but that he/she often continued the behaviors despite re-direction. LN #4 did not think the language was aggressive but that the Resident perpetrator, was asking for a change in the situation by voicing his/her displeasure about living with people of a race he/she felt was undesireable. LN #4 did not know if there was an investigation or action taken to protect Resident #6 from further abuse. During an interview on 8/22/19 at 2:00 pm, the Director of Nursing (DON) stated there was not any additional policy or procedure that addressed Resident to Resident verbal, physi… | 2020-09-01 |
| 24 | 24 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 610 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure that a resident was from free from racially directed verbal abuse by another resident for 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause the resident to experience humiliation, shame and/or degradation. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 8/21/19 at 8:14 am, Resident #6 stated that another Resident of the facility had used racially biased language directed at him/her. Resident #6 further stated that staff blew off Resident #6's concerns by making excuses for the other Resident. Resident #6 identified a single Resident as the perpetrator of the verbal abuse and stated that staff had not done anything to address the abuse or prevent it from re-occurring. Resident #6 stated that he/she was directed to avoid the perpetrator or go to his/her room if the perpetrator was present in common areas. Resident #6 stated he/she felt insulted and abused by the racial verbal abuse and was angry that staff did not make efforts to address the abuse. During an interview on 8/21/19 at 10:00 am, Licensed Nurse (LN) #4 stated that he/she had heard of altercations between Resident #6 and the alleged perpetrator. LN #4 stated that re-direction was given to the perpetrator but that he/she often continued the behaviors despite re-direction. LN #4 did not think the language was aggressive but that the Resident perpetrator was asking for a change in the situation by voicing displeasure about living with people of a race he/she felt living with was undesirable. LN #4 did not know if there was an investigation or action taken to protect Resident #6 from further targeted abuse. During an interview on 8/22/19 at 2:00 pm, the Director of Nursing (DON) stated there was not any additional policy or procedure that addressed Resident to Resident verbal… | 2020-09-01 |
| 25 | 25 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 637 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement care plan interventions within 14 days after an identified significant change in a resident's physical condition that impacted the ability to maintain independence and complete activities of daily living for 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause further decline in the resident's ability to complete independent hygiene and self-care activities. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6 had difficulty walking and used a wheelchair for mobility. During an interview on 8/21/19 at 8:32 am, Resident #6 stated that he/she was concerned because he/she had gained approximately 80 pounds since admission. Resident #6 stated that the facility had not addressed his/her weight gain. Resident #6 stated the weight gain had caused difficulty to independently attend to activities of daily living. Record review of the weight chart revealed that Resident #6 weighed 166.2 kilos on 2/27/19 and 191.1 on 8/20/19. The weight calculator revealed a 14.98% weight gain in slightly less than 6 months. During an interview on 8/21/19 at 1:53 pm, Resident #6 stated that he/she had discussed the weight gain with both the doctor and the dietitian. Resident #6 further stated he/she had not been provided with any information or options to address the weight gain. During an interview on 8/21/19 at 3:16 pm, the Registered Dietitian (RD) stated that Resident #6 was difficult because he/she would not follow diet recommendations, bought food from outside, and failed to follow recommendations of the staff and RD. The RD further stated that the weight gain could be due to fluid retention, that Resident #6 had been on fluid restriction, but that there were not current restrictions. Record review of Resident #6's admission MDS (Minimum Data Set- a federally mandated assessment too… | 2020-09-01 |
| 26 | 26 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 657 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update and revise the care plan to reflect the current care and services for 2 residents (#s 6 and 17) out of 14 sampled residents. This failed practice placed the residents at risk for not receiving appropriate and/or necessary care and services. Findings: Resident #6 Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6 had difficulty walking and used a wheelchair for mobility. During an interview on 8/21/19 at 8:32 am, Resident #6 stated that he/she was concerned because he/she had gained approximately 80 pounds since admission. Resident #6 further stated the facility had not addressed his/her weight gain and the weight gain had caused difficulty to independently attend to his/her activities of daily living. Record review of the weight chart revealed Resident #6 weighed 166.2 kilograms on 2/27/19 and 191.1 kilograms on 8/20/19. The weight calculator revealed a 14.98% weight gain in less than 6 months. During an interview on 8/21/19 at 1:53 pm, Resident #6 stated he/she had discussed the weight gain with both the doctor and the dietitian. The Resident further stated he/she had not been provided with any information or options to address the weight gain. During an interview on 8/21/19 at 3:16 pm, the Registered Dietitian (RD) stated Resident #6 was difficult because he/she would not follow diet recommendations, bought in food from outside the facility, and failed to follow recommendations of the staff and RD. The RD further stated the weight gain could be due to fluid retention and Resident #6 had been on fluid restrictions, but that there were no current restrictions. Record review of Resident #6's most recent MDS (Minimum Data Set- a federally mandated assessment tool), a quarterly assessment dated [DATE], revealed the increased need for assistance in the following areas of functional status independence; 1) transfer f… | 2020-09-01 |
| 27 | 27 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 684 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide treatment in accordance with professional standards for 1 (#10) resident out of 14 sampled residents. Specifically, the resident was receiving oxygen without a physician's order. This failed practice placed the resident at risk for receiving less than optimal care and incorrect treatments. Findings: Record review from 8/19-23/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set, a federally required nursing assessment), assessment dated [DATE] revealed the Resident did not use oxygen therapy. Review of Resident #10's H&P (history and physical), dated 6/17/19, revealed Continue respiratory medications .oxygen as needed. An observation on 8/19/19 at 4:00 pm revealed the Resident lying in bed with his/her eyes closed and wearing oxygen via nasal cannula (oxygen delivery system tubing). During an interview on 8/20/19 at 9:45 am, Resident #10 stated he/she wore oxygen mostly while he/she slept. The oxygen in the Resident's room was turned on at 3 l/min (liter per minute of oxygen flow). The nasal cannula was positioned next to the Resident in the Resident's bed. During an interview on 8/22/19 at 8:40 am, Licensed Nurse (LN) # 4 stated Resident #10 used oxygen as needed. LN #4 further stated that the Resident would use the oxygen when the Resident had chest pain. During an interview on 8/22/19 at 12:40 pm, LN # 2 stated Resident #10 used oxygen as needed. He/she would check the Resident's oxygen saturation (a noninvasive test to see how much oxygen is in the blood stream) and would provide the Resident oxygen as needed. A review of Resident #10's most recent physician's orders with LN # 2 revealed no physician order for [REDACTED].# 2 further stated that he/she would call the physician for the oxygen order. During an interview on 8/22/19 at 1:44 pm, LN # 4 stated he/she did not know if a physici… | 2020-09-01 |
| 28 | 28 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 686 | D | 1 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure one resident #2 (out of 4 residents) reviewed for pressure injuries, did not develop an avoidable stage 2 pressure injury(partial thickness skin loss with exposed dermis (second layer of skin)presenting as a shallow open ulcer) . This failed practice caused the resident unnecessary pain, an increased risk for infection, and the potential for poor medical outcome. Findings: Pressure injury According to the National Pressure Ulcer Advisory Panel, accessed 9/7/19 at www.nouap.org A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Record review from 8/20-23/19 revealed Resident # 2 was admitted to facility with [DIAGNOSES REDACTED]. a clot of blood), and [MEDICAL CONDITION]. Review of the most recent Minimum Data Set (MDS-a federally mandated assessment) a quarterly assessment dated [DATE] revealed the Resident had no pressure injuries. Further review of the MDS revealed Resident #2 was non-ambulatory, totally dependent on staff for bed movement, locomotion in the wheelchair, bathing, and needing extensive assistance (requiring two personal physical assistance) for dressing, toileting, transfers, and personal hygiene. Review of Resident #2's care plan Problem: Additional Communication Problem .Start: 9/07/18 Description: (Resident) is non-verbal, unable to speak .Problem: Requires extensive assistance/dependent with mobility and ADL's (activities of daily living) .Goal: Resident will receive max (maximum) assistance with mobility and ADL's .Sta… | 2020-09-01 |
| 29 | 29 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 687 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure proper treatment and care was provided to maintain good foot health in accordance with professional standards was provided to 1 resident (#6) out of 14 sampled residents. This failed practice had the potential to cause the resident discomfort and prevent necessary foot care to prevent development of foot problems secondary to the disease process. Findings: Record review on 8/19-23/19 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6 had difficulty walking and used a wheelchair for mobility. During an interview on 8/21/19 at 8:45 am, Resident #6 stated that he/she needed to have his/her toenails trimmed. Resident #6 stated that he/she had asked nursing staff for several months and was told a podiatrist appointment had to be scheduled. Resident #6 was concerned about his/her feet as he/she was unable to complete the task independently. Record review on 8/21/19 at 10:00 am, of Resident #6's undated, most recent care plan provided by facility staff, revealed for the problem area of Alteration in skin integrity, an intervention that Resident #6 would receive, .weekly full body skin and nail assessment by primary RN, with a start date of 2/27/19. There were no documentation of toenail assessment and findings. During an observation on 8/21/19 at 1:06 pm, Resident #6's toenails were long, some were jagged from being broken, and his/her socks caught on the jagged pieces. During an interview on 8/21/19 at 1:08 pm, when asked how often residents get nail care, Certified Nurse Assistant (CNA) #2 stated as needed. When asked if Resident #6's toenails looked like they needed trimmed, CNA #2 stated yes. During an interview on 8/21/19 at 1:10 pm, LN #4 stated that if the Resident was not diabetic, toenails could be clipped by facility staff. LN #4 further stated that nursing staff would review, and if needed, would make an appointment with… | 2020-09-01 |
| 30 | 30 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 689 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure; 1) a malfunctioning bed was recognized and removed from service in a timely manner for 1 (#17) out of 14 sampled residents, and 2) staff were trained on the proper use of the bed. Specifically, the resident was lying in a malfunctioning bed for an unknown length of time. This failed practice created a potential risk for harm and/or injury from 1) potential improper inflation leading to increased risk of pressure ulcers and 2) risk of entrapment from potentially improper inflation of the mattress and impingement of bed rails. Findings: Record review from 8/19-23/19 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An observation on 8/19/19 at 4:00 pm, revealed the Resident lying on an air mattress in his/her [NAME]-rom (a brand of facility) bed, with both upper 1/2 bed rails in the up position. The monitor at the foot of the bed was blinking with a service required message, and a yellow light was illuminated below the monitor. An observation on 08/20/19 at 1:49 pm, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor read please call [NAME]-rom [PHONE NUMBER] service code 7,and a yellow light was illuminated below the monitor. An observation on 08/21/19 at 2:47 pm, revealed the Resident's bed was functioning properly. There was no error message and a green light was illuminated. A dressing change to the Resident's head was attempted by Licensed Nurse (LN) #1. LN #1 lowered the head of the Resident's bed prior to the procedure. Once the head of the bed was lowered, the service required message reappeared on the monitor, and the yellow light was illuminated. When the head of the bed was raised back up, the air mattress began working properly. During an interview on 8/21/19 at 2:49 pm, LN #1 stated he/she was not aware of any problems with the Resident's air mattress. An observation on 8/22/19 … | 2020-09-01 |
| 31 | 31 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 690 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 1 resident's (#8) catheter, of 4 sampled residents with an indwelling catheter, was secured to prevent free movement of tubing and discomfort. This failed practice placed the resident at risk for discomfort, pain, trauma and further catheter complications. Findings: Urinary Catheter or UTI Resident #8 Review of the most recent quarterly Minimal Data Set (MDS-federally required nursing assessment), dated 6/18/19, revealed Resident #8 was coded as having an indwelling catheter. During an observation on 8/20/19 at 2:00 pm revealed Certified Nurse Assistant (CNA) #3 was providing activities of daily living cares to Resident #8. While the CNA was dressing the Resident, the catheter tubing was noted to be passed through a securing device adhered to Resident #8's left inner thigh. The clamp on the securing device ([MEDICATION NAME] Foley Stabilization Device) was over the tan-colored catheter tubing approximately 4 inches above the bifurcation section (area that contained the balloon control port and the connection to the clear drainage tubing). As a result, the tan-colored tube was observed to freely slide up and down through the securing device. During an interview on 8/20/19 at 2:00 pm, CNA #3 was asked if the catheter tube was properly secured to the Resident's left inner thigh. CNA #3 stated the securing device should have held the tubing in place. During a subsequent observation on 8/20/19 at 2:10 pm, CNA #3 proceeded to secure the tubing in the securing device but was unable to do so successfully. During the CNA's attempt to secure the catheter tubing, Resident #8 yelled out in discomfort and stated it was uncomfortable when the CNA was pulling on the catheter tubing. During an observation on 8/21/19 at 1:09 pm, Licensed Nurse (LN) #4 assessed the securing device for Resident #8's catheter. LN #4 stated the catheter tubing was not properly held in place by the sec… | 2020-09-01 |
| 32 | 32 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 812 | F | 1 | 1 | 0OWF11 | > Based on observation, interview and record review the facility failed to ensure: 1) Food was stored, prepared and distributed in a safe and/or sanitary manner in accordance with professional standards and 2) the environment was maintained and monitored in a clean and sanitary condition. This failed practice placed all residents (based on a census of 21) at risk for foodborne illness. Findings: Food Storage/Cleanliness: During random observations on 8/19/19 of the central kitchen's dry storage area revealed: - 27 eight ounce cans of Nepro Supplement with best by dates of 8/1/19; - 1 case of Tostito's chips stored on the floor; - Shredded Sauerkraut (6 lbs 3 oz) with large dent located on the seal; - Sliced nacho jalapeno peppers with a 2 inch dent located just below the can's seal; and - 50 oz can of cream of mushroom with 1 inch dent located on the can's seal. During an interview on 8/19/19 at 2:00 pm the Dietary Manager stated the items identified in the dry storage should have been removed. Review of the U.S. Department of Health and Human Services (USDHHS) - Food and Drug Administration (FDA) Food Code, dated (YEAR), revealed Food shall be safe, unadulterated .dented cans may .present a serious potential hazard. During random observations on 8/19/19 of the central kitchen's walk-in cooler revealed a cracked and leaking plastic container of thawed pot roast. A leak of red tinged fluid that was dripping on the shelving unit and on the top of the plastic bin just below the pot roast. Review of the USDHHS - FDA Food Code, dated (YEAR), revealed food shall be protected from cross contamination by separating raw animal foods during storage. During an interview on 8/19/19 at 2:10 pm the Dietary Manager stated he/she was unaware of the leaking container and it should have been removed from service. During an observation on 8/19/19 of the central kitchen's walk-in freezer revealed a four pound package of salami slices that were open-to-air. The salami slices had frozen white crystals and appeared to be pale and green… | 2020-09-01 |
| 33 | 33 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 837 | F | 0 | 1 | 0OWF11 | Based on document review and interview, the facility failed to ensure an engaged and involved governing body was responsible for establishing and implementing policies regarding management and operation and management of the facility. This filed practice had the potential to effect all residents, based on a census of 21, to receive less than optimal care. Findings: Document review on 8/23/19 at 10:14 am, of the Community Health Board minutes, identified by the Administrator (AD) as the Governing Body (GB), revealed no information on reporting, policies, management or operation of the long term care (LTC) facility for the past 12 months. The content of the minutes was strictly related to hospital governance. During an interview on 8/23/19 at 10:16 am, the AD stated there was no LTC representative who reported information to the GB. The AD further revealed there had been no reports submitted to the GB. The AD had tried to get on the agenda and had been cancelled. The AD stated there is no GB oversight for the LTC. | 2020-09-01 |
| 34 | 34 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 838 | F | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review,observation, interview, and facility document review the facility failed to develop a process to train staff on the use of standard and specialized equipment to meet residents complex medical needs. Specifically, the facility assessment did not include a training plan for staff on new, replacement, or resident specific equipment. This failed practice had to potential to effect all residents, based on a census of 21, to receive less than optimal care: Findings: Resident #17 Record review from 8/19-23/19 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An observation on 8/19/19 at 4:00 pm, revealed the Resident lying on an air mattress in his/her [NAME]-rom (a brand of facility) bed, with both upper 1/2 bed rails in the up position. The monitor at the foot of the bed was blinking with a service required message, and a yellow light was illuminated below the monitor. An observation on 8/20/19 at 1:49 pm, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor read please call [NAME]-rom [PHONE NUMBER] service code 7,and a yellow light was illuminated below the monitor. An observation on 08/21/19 at 2:47 pm, revealed the Resident's bed was functioning properly. There was no error message and a green light was illuminated. A dressing change to the Resident's head was attempted by Licensed Nurse (LN) #1. LN #1 lowered the head of the Resident's bed prior to the procedure. Once the head of the bed was lowered, the service required message reappeared on the monitor, and the yellow light was illuminated. When the head of the bed was raised back up, the air mattress began working properly. During an interview on 8/21/19 at 2:49 pm, LN #1 stated he/she was not aware of any problems with the Resident's air mattress. An observation on 8/22/19 at 8:01 am, revealed Resident #17 lying in bed, with both upper 1/2 bed rails in the up position. The monitor of resident's… | 2020-09-01 |
| 35 | 35 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 880 | F | 0 | 1 | 0OWF11 | Based on observations and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment in the central kitchen. This failed practice placed all residents (based on a census of 24) at risk for food borne illnesses. Findings: Random observations and interviews from 8/19-22/19 revealed multiple deficiencies noted in food handling (single-use gloves during food plating), food storage, cleanliness of environment and competencies in the sanitation process. During an interview on 8/22/19 at from 8:00 am to 9:30 am, the Infection Preventionist (IP) was asked what oversight the Infection Control Program had in the dietary department, The IP stated he/she completed an annual walkthrough but was overdue for an evaluation of the central kitchen. When asked if he/she provides any infection control in-services to the dietary staff, the IP stated he/she would only conduct in-services if a deficiency or gap in education was identified. The IP further stated the last infection control in-service conducted for dietary staff was over year ago. The IP stated he/she was not aware of the systematic failures in the kitchen and an evaluation needed to be conducted. During an interview on 8/22/19 at 9:14 am the Administrator stated that the facility's infection control program should have been conducting more frequent oversight due to the deficiencies and systematic failures noted by the State Survey Agency. | 2020-09-01 |
| 36 | 36 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 909 | E | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 2 sampled residents' (#s 2 and 7) and 1 non-sampled resident's (#21) bed mattresses out of 24 residents reviewed were inspected and maintained in a safe manner to reduce the risk of improper use and entrapment. Specifically, the facility failed to ensure the mattresses were appropriately fitted in the bed frame. This failed practice place the residents at risk for entrapment and less than optimal comfort level while in bed. Findings: Resident #2 Record review from 8/19-22/19 revealed Resident #2 had a history of [REDACTED]. Review of the most recent annual Minimum Data Set (MDS - a federally required assessment), dated 8/22/19, revealed Resident #2 was coded as having severely impaired cognitive skills for daily decision making. During random observations from 8/19-22/19 revealed Resident #2's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. Resident #7 Record review from 8/19-22/19 revealed Resident #7 had a history of [REDACTED]. Review of the admission MDS, dated [DATE], revealed Resident #7 was coded as having severely impaired cognitive skills for daily decision making, as well as having short and long term memory problems. During random observations from 8/19-22/19 revealed Resident #2's mattress was pushed against the footboard of the bed and curved upwards approximately 4 to 6 inches. Further observation revealed a 2 - 4 gap between the headboard and the mattress. Resident #21 Record review from 8/19-22/19 revealed Resident #7 had a history of [REDACTED]. Review of the most recent MDS dated [DATE], revealed Resident #21 was coded as having severely impaired cognitive skills for daily decision making; short and long term memory problems; and disorganized thinking. During random observations from 8/19-22/19 revealed Resident #2… | 2020-09-01 |
| 37 | 37 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-10-11 | 609 | E | 1 | 0 | 566T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure allegations of potential neglect were reported to the appropriate officials in accordance with State law, including to the State Survey Agency, within required time frames and facility policy. Specifically, the facility failed to notify the State Survey Agency and the State Medical Board in the required timelines set forth by federal and/or state regulation/statute/law. This failed practice caused 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10) out of 27 residents to have received physician care and services not in accordance with State law and had the potential to cause further allegations of neglect. Findings: Review of the facility provided physicians' schedule, dated [DATE] to [DATE], revealed Physician #1 was scheduled and employed by the facility. Record review of the CareConnect Provider Activity Report, dated [DATE] to [DATE] revealed Physician #1 provided care and/or services to 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10). Review of Alaska's Division of Corporations, Business and Professional Licensing under the Department of Commerce, Community, and Economic Development website, accessed at https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing.aspx on [DATE], revealed Physician #1 had a lapsed licensure status from [DATE] to [DATE]. During an interview on [DATE] at 1:20 pm, the Long Term Care (LTC) Administrator stated the LTC facility was made aware of Physician #1 [MEDICATION NAME] without a license from [DATE] to [DATE] on [DATE]. The Administrator further stated the facility did not report the event to the State Agency until [DATE]. Review of the facility policy State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act, dated [DATE], revealed In accordance with Alaska state law, 42CFR483.13(b)(c), all suspected cases of abuse and/or neglect will be reported as outlined below: Health Facilitie… | 2020-09-01 |
| 38 | 38 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-10-11 | 839 | F | 1 | 0 | 566T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure a physician retained a current licensure under Alaska Statute (AS) 08.64.170 and 12 Alaska Administrative Code (AAC) 40. This failed practice placed 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10) out of 27 residents at risk for receiving care and services from an unlicensed physician. Findings: Review of the facility provided physicians' schedule, dated [DATE] to [DATE], revealed Physician #1 was scheduled and employed by the facility. Record review of the CareConnect Provider Activity Report, dated [DATE] to [DATE] revealed Physician #1 provided care and/or services to 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10). Review of Alaska's Division of Corporations, Business and Professional Licensing under the Department of Commerce, Community, and Economic Development website, accessed at https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing.aspx on [DATE], revealed Physician #1 had a lapsed licensure status from [DATE] to [DATE]. Record review of the facility document Actions to Notify (Physician #1) Professional Licensure Expiration, undated, revealed the following timeline: [DATE] - Credential Verification Office (CVO) sent notification to the Provider Administrative Coordinator (PAC) of Physician #1 licensure expiration on [DATE]. [DATE]; [DATE]; [DATE]; [DATE]; [DATE] - The PAC sent email communication to Physician #1 with no response. The document indicated the facility did not have documentation to confirm these communication attempts. [DATE] - The PAC sent a copy of Physician #1's licensure to the CVO stating his/her license had been renewed and had a new expiration of [DATE]. However, the PAC sent a copy of the current licensure that had an expiration of [DATE]. The license for Physician #1 was not renewed at this time as indicated by the PAC. [DATE] - The CVO notified the PAC that he/she sent the expiring licensure for Physician #1 and confirmed it … | 2020-09-01 |
| 39 | 39 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 558 | E | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure that resident needs were accommodated for 1 resident (# 1), out of 8 sampled residents. Specifically, the facility failed to ensure the call light was accessible while a resident was in his/her room. This failed practice inhibited the residents' ability to call for assistance and placed the resident at risk for a delay in receiving care. Findings: Record review from 4/15-19/19 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Resident #1's care plan revealed Resident #1 was at risk for falls with interventions to include frequent reminders to slow down .use footwear .ask for help at night when unsteady .and ensure (his/her) call bell is within reach. During an interview on 4/16/19 at 10:07 am, Resident #1 stated that he/she was unsure where the call light was in his/her new bedroom. Resident #1 further stated that he/she would not know how to contact staff if he/she needed help in the bedroom. Observation on 4/16/19 at 10:14 am of Resident #1's bedroom revealed the call light and cord were wound up and hanging on the wall over the oxygen supply valve near the room curtain divider approximately two feet above the bedside table. Further review revealed Patient #1 was not able to reach the call light from his/her wheelchair. Observation on 4/17/19 at 8:52 am and 4/18/19 at 8:20 am revealed the call light and cord remained coiled on the wall over the oxygen supply valve. During an interview on 4/19/18 at 8:25 am, the Director of Nursing (DON) stated that every resident should have access to their call lights and the call lights should never be out of reach. The DON further stated that staff do frequent rounding and that she would be surprised if a resident did not know where the call light was in the room. During an interview on 4/19/18 at 8:31 am, the DON stated there was no policy on call lights. During an interview on 4… | 2020-09-01 |
| 40 | 40 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 568 | F | 0 | 1 | FNNN11 | Based on record review and interview the facility failed to provide quarterly statements of personal funds accounts to 6 residents (#1, 5, 6, 7, 8, and 10), out of 8 sampled residents. This failed practice placed all residents (based on a census of 12) at risk for not receiving a complete and accurate accounting of their personal funds entrusted to the facility. Findings: Review of the facility personal fund accounting record, on 4/18/19 at 12:50 pm, revealed Residents #1, 5, 6, 7, 8, and 10 had personal fund accounts through the facility. During an interview on 4/18/19 at 1:10 pm, the Personal Funds Manager stated the facility did not have a process for providing residents or their representatives a quarterly statement, and as a result, the facility did not provide residents or their representatives quarterly statements of their personal fund accounts. During an interview on 4/19/19 at 11:00 am, the Director of Nursing (DON) stated the facility does not have a policy on personal funds. | 2020-09-01 |
| 41 | 41 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 570 | F | 0 | 1 | FNNN11 | Based on record review and interview the facility failed to acquire a surety bond that would financially cover all potential funds within personal funds accounts for 6 residents (#1, 5, 6, 7, 8, and 10), out of 8 sampled residents. This failed practice placed all residents (based on a census of 12) at risk for not being compensated for the potential loss of personal funds entrusted to the facility. Findings: Review of the facility personal fund accounting record, on 4/18/19 at 12:50 pm, revealed Residents #1, 5, 6, 7, 8, and 10 had personal fund accounts. During an interview on 4/18/19 at 1:10 pm, the Personal Funds Manager stated the maximum amount of cash a resident can have within their personal funds account was $50.00. He/she stated if a resident or their family brought in more than $50.00 to add to their personal funds account, he/she would inform them a checking account would need to be opened at the bank for the extra money over the $50.00 limit. Review of the facility's surety bond Patient Trust Funds Bond, dated 1/14/19, revealed the bond amount was $1,000.00. During an interview on 4/18/19 at 1:25 pm, the Finance Manager stated the surety bond was only for $1,000.00 because residents at the facility could only have $50.00 in their personal funds accounts. He/she stated the total amount for the surety bond was calculated and based off of the $50.00 limit per resident. During an interview on 4/19/19 at 11:00 am, the Director of Nursing (DON) stated the facility does not have a policy on personal funds. | 2020-09-01 |
| 42 | 42 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 585 | D | 0 | 1 | FNNN11 | Based on record review, interview and policy review, the facility failed to provide a written response to 1 resident's (#7) grievance that included: a statement that the grievance was confirmed/not confirmed; actions to be taken by the facility; date grievance was resolved; and date the written decision was given to the resident. This failed practice denied 1 resident (out of a census of 12) their right to participate in improving their experience and to receiving responses in a timely manner. Findings: Record review on 4/17/19 at 8:43 am, of the grievance log revealed there was no follow up process or outcome recorded for a grievance filed by Resident #7 on 12/27/18. The facility was unable to provide evidence that the grievance was resolved in a timely manner or that a written decision was provided in response to the grievance. During an interview on 4/17/19 at 8:45 am, the Grievance Officer (GO) revealed that he/she had not documented the investigation to address the grievance, nor did he/she document the date the grievance was resolved. The GO further stated the issue was resolved several months later, however, could not recall an actual date of completion, and did not provide a written response to the resident. Review on 4/16/19 of the facility's policy entitled, Grievance Policy, last reviewed on 3/2019, revealed, The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .the Compliance (Grievance) Officer will receive and track grievances through to their conclusion .the resident .will be informed by written decision and this will include: a) The date the grievance was received. b) A summary statement of the grievance received. c) The steps taken to investigate the grievance. d) A summary of the pertinent findings or conclusions regarding the grievance. e) A statement as to whether the grievance was confirmed or not confirmed. f) Any corrective action taken or to be taken by the facility as a result of the grievance. g) The date the… | 2020-09-01 |
| 43 | 43 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 623 | D | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to incorporate all required contents in a written notice of discharge prior to mailing this notice to 1 resident's (#3) representative, out of 8 sampled residents. This failed practice placed the resident at risk for being inappropriately discharged from the facility. Findings: Record review on 4/15-19/19 revealed Patient #3 was admitted to the facility with [DIAGNOSES REDACTED]. This includes an increased risk of violence, aggressive behavior) and physical deconditioning (a physical and psychological decline in function). Record review revealed a Notice of Intent to Discharge, dated 4/10/19, that was mailed to Resident #3's representative, who was his/her power of attorney (POA), on 4/11/19. Review of the notice revealed the reasons for this action were: 1) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility and 2) The safety of individuals (other residents) in this facility if endangered. Further review revealed the location to be discharged and date of discharge were documented as yet to be determined. During an interview on 4/19/19 at 3:10 pm, the Director of Nursing (DON) stated Resident #3's Notice of Intent to Discharge was sent to the POA without a facility/location identified, or date of discharge. He/she stated he/she was unaware these stipulations needed to be ascertained prior to notification. | 2020-09-01 |
| 44 | 44 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 637 | D | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to identify a significant change in condition for 1 resident (#10), out of 8 sampled residents. Specifically, the facility failed to complete a significant change in status assessment for the care areas of mood and ADLs (activities of daily living), within 14 days from the time the significant change should have been identified. This failed practice placed the resident at risk for not receiving interventions and care to maintain the highest practicable level of well-being. Findings: Resident #10 Record review on 4/15-19/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Mood: Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment), a quarterly assessment dated [DATE], revealed Resident #10 was coded as having no trouble falling or staying asleep. Review of Resident #10's Physician Notes, dated 2/20/19 at 2:56 pm, revealed Asked to be assessed because of increasing confusion, decreasing mobility, and ongoing [MEDICAL CONDITION] .This is a mild to moderate decrease from (him/her) regular level of functioning. Review of Resident #10's Nurses Notes, dated 2/22/19 at 5:24 am, revealed Resident was restless last night. Up and down multiple times. Further review revealed Resident #10 had restlessness or yelling out on the nights of 2/10-13/19, and [MEDICAL CONDITION] on 2/26/19. Review of Nurses Notes, dated 3/6/19 at 2:49 pm, revealed Resident #10's .behavior last evening was a significant change from normal .(He/She) asked to go to the bathroom [ROOM NUMBER] times in an hour .(He/She) kept calling out that (he/she) was falling out of bed. Review of Physician Notes, dated 3/15/19 at 4:34 pm, revealed Resident #10 .had increasing difficulties with middle of the night [MEDICAL CONDITION] .This has occurred 12 nights this month with increasing frequency. During an observation on 4/15/19 at 2:20 pm, the Physician had as… | 2020-09-01 |
| 45 | 45 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 641 | D | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure pressure ulcers were accurately coded on a significant change MDS (Minimum Data Set - A Federally mandated nursing assessment) for 1 Resident (#10), out of a sample of 8 residents. This failed practice had the potential to inaccurately reflect the resident's status and care planning and placed the resident at risk of physical and psychosocial decline. Findings: Record review from 4/15-19/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS, a Significant Change assessment, dated 4/3/2019, revealed that Resident #10 was coded as having one Stage II pressure ulcer (pressure injury to the skin that involves partial-thickness skin loss with exposed under skin layers. Wound is pink or red, moist, and may be intact or a ruptured serum-filled blister). During an interview on 4/19/19 at 11:04 am, the MDS Coordinator stated that she was aware of the pressure ulcer to Resident #10's left foot, but unaware of a second pressure ulcer to the Resident's right toe. The MDS Coordinator reviewed the most recent MDS dated [DATE] and stated I must have missed it. Review of the facility policy and procedure entitled, Resident MDS Assessment and Care Planning revealed: All residents will have Comprehensive Assessment completed on admission, Annually, and with any Significant changes . the purpose of the policy is to provide interdisciplinary observation and assessment to ensure the most accurate assessment of functional capacity .Risk Factors and Assessment to be completed by a nurse .Braden, Pressure Ulcer Risk, Urine Incontinence Risk, Fall Screen, Constipation Screen, Risk of Dehydration, Risk of Elopement, Risk for skin tears, additional assessments as needed . | 2020-09-01 |
| 46 | 46 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 656 | D | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a resident-centered care plan, based on dental care needs identified during an MDS (Minimum Data Set, a federally required nursing assessment) assessment for 1 resident (#4), out of 8 sampled residents. This failed practice delayed dental care/repair of loose dentures which placed the resident at risk for impaired nutritional intake, as well as, optimal health and well-being. Findings: Record review on 4/15-19/19 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. (MONTH) manifest as weight loss, decreased appetite, poor nutrition, and inactivity). Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, an admission assessment dated [DATE], revealed Resident #4 was coded as having broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Review of Care Area Assessment (CAA) Summary of the admission MDS assessment revealed dental care was a care area triggered within the MDS and should have been addressed in Resident #4's care plan. Review of Resident #4's care plan, start date 3/15/19, revealed dental/dentures were not an identified problem. There were no goals or interventions associated to dental/denture care. During an interview on 4/16/19 at 1:32 pm, Resident #4's Daughter stated Resident #4's dentures are too big and they fall out of his/her mouth at times and this had affected his/her ability to chew. The Daughter stated the facility had not mentioned to her what they were going to do about Resident #4's dentures. During an interview on 4/16/19 at 3:42 pm, the Senior Office Specialist stated all appointments, to include dental appointments, for the Long Term Care Residents were logged in the appointment book kept at the front desk. He/she stated there had been no dental appointments made for Resident #4. During an interview on 4/17/19 at 9:15 am, the M… | 2020-09-01 |
| 47 | 47 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 657 | F | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation the facility failed to ensure resident care plans were reviewed and revised based on MDS (Minimum Data Set - A federally required nursing assessment) assessments for 6 residents (#1, 3, 8, 9, 10, 11), out of 8 sampled residents. This failed practice placed the residents at risk for not receiving care/services to maintain the highest practicable mental, physical, and psychosocial well-being. Findings: Care Plan Reviews and Revision Process: During an interview on 4/16/19 at 10:00 am, Registered Nurse (RN) #1 stated the most recent care plans for residents were kept in a binder in the dining room/common area of the unit for staff to review when providing care to the residents During an interview on 4/16/19 at 2:00 pm, RN #1 stated that care plans were reviewed and revised by the MDS Coordinator. During an interview on 4/17/19 at 8:50 am, the MDS Coordinator stated care plans were reviewed during quarterly MDS reviews or when a significant change occured. The start date on the care plan identified problems and interventions indicated the date of the MDS finalization or when the problem was identified. The review date indicated when the next quarterly MDS was due and when the problem, goals, and interventions needed to be evaluated. The MDS Coordinator further stated changes would be made based on that quarterly review, or if any changes had come to light based on the resident's care. He/she stated the review dates for all categories identified in the care plan should move forward, to the next scheduled assessment date of the MDS quarterly review or MDS assessment, to show they remain active and up to date. Observation on 4/17/19 at 3:30 pm revealed Resident care plans were placed in a binder located in the common area of the unit. Sticky notes were placed on the care plans from all staff to share information that should be updated in the care plan. During an interview on 4/17/19 at 3:53pm, RN #1 … | 2020-09-01 |
| 48 | 48 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 761 | D | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to label drugs and biologicals in accordance with currently accepted professional practices. Specifically, the facility failed to: 1) ensure the expiration date on a bottle of [MEDICATION NAME] tablets (a heart medication to treat and prevent chest pain caused due to heart complications) was readable for 1 resident (#1), out of 12 medication drawers inspected and 2) ensure glucometer control solutions (solutions used to perform quality checks on glucometers (a device that measures blood sugar concentrations in the blood) to ensure accurate readings) were properly labeled with open dates. This failed practice placed residents at risk for not receiving effective and accurate nursing interventions for potentially life-threatening conditions. Findings: Resident #1 Record review on 4/15-19/19 revealed Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Further review revealed Resident #1 had a pacemaker (a small device implanted near the heart that provides a small electric stimulation to help the heart beat more regularly). Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #1 was coded as having unspecified [MEDICAL CONDITION] (an irregular, often rapid heart rate that commonly causes poor blood flow) and [MEDICAL CONDITIONS] of native coronary artery (a buildup of plaque inside the artery walls in the heart which causes narrowing of the arteries and slows the blood flow. This affects the blood supply to the heart). Review of Resident #1's medical record revealed a medication order for [MEDICATION NAME] 0.4mg tablet (sublingual - under the tongue) every 5 minutes as needed for chest pain. Call (doctor) if no relief after 3rd dose. Monitor for [MEDICAL CONDITION] (low blood pressure) [MEDICATION NAME]. Observation on 4/17/19 at 11:24 am, of Resident #1's m… | 2020-09-01 |
| 49 | 49 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 790 | D | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility to obtain dental services for 1 resident (#4), out of 8 sampled residents. Specifically, the facility failed to provide service to fix loose dentures. This failed practice affected the resident's ability use his/her dentures effectively and maintain a general diet. Findings: Record review on 4/15-19/19 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. (MONTH) manifest as weight loss, decreased appetite, poor nutrition, and inactivity). Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, an admission assessment dated [DATE], revealed Resident #4 was coded as having broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Further review revealed the assessment indicated no altered or therapeutic diets were needed. Review of Care Area Assessment (CAA) Summary of the admission MDS assessment revealed dental care was a care area triggered within the MDS and would have been addressed in Resident #4's care plan. Review of Resident #4's care plan, start date 3/15/19, revealed dental/dentures were not an identified problem. There were no goals or interventions associated to dental/denture care. Review of the Physician Orders for Resident #4 revealed a diet order, dated 3/2/19, food consistency general. Review of (Wrangell Medical Center) Nutritional Assessment, dated 4/12/19 revealed Nutrition Related Assessment Comments: Dentures are apparently loose per MDS . The plan on the assessment indicated add (mechanical) soft to order for ease of chew. During an interview on 4/16/19 at 12:52 pm, the Dietician stated Resident #4 was placed on mechanical soft diet (ground meat) because his/her dentures were loose and it would ease Resident #4's ability to chew meat. During an interview on 4/16/19 at 1:32 pm, Resident #4's Daughter stated Resident #4's dentures were too big and they fell out of his/he… | 2020-09-01 |
| 50 | 50 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 804 | D | 0 | 1 | FNNN11 | Based on interview, observation, and policy review, the facility failed to ensure that food was prepared by methods to conserve nutritive value. Specifically, there was no consistent method for preparing pureed diets and the addition of thickening powder for 1 non-sampled resident (#6) out of census of 12. This failed practice had the potential to decrease the nutritive value of pureed foods and placed residents on a pureed diet at risk for weight loss. Findings: During an interview on 4/15/19 at 8:45 am, Cook #1 stated he/she used water to puree breakfast items such as pancakes and French toast. Cook #1 further stated that he/she would add syrup to the water to improve flavor. Cook #1 further stated that she used broth for meats and apple juice for sweet items. During an observation on 4/16/19 at 12:45 pm, Cook #1 measured 4 ounces of salmon then poured an unmeasured amount of broth into the blender canister to puree the salmon. The Cook then proceeded to add thickener a little bit at a time with the measured scoop until it was the consistency desired. The process was repeated for the rice pilaf and carrots. During an interview on 4/16/19 at 1:00 pm, Cook #1 stated that the puree was to be honey thick consistency and that he/she eyeballs the puree until it appeared to be at the texture he/she desired. During an interview on 4/17/19 at 12:30 pm, when asked about the pureed lunch meal preparation, Cook #1 stated there was thickener in the sherbet, mashed potatoes, roast beef, and carrots. When asked if there were guidelines available for pureeing diets in the kitchen, he/she stated there were none that he/she knew of. During an interview on 4/17/19 at 12:45, Cook #2 stated that he/she prepared the pureed lunch items and that there was only thickener in the sherbet. He/she stated they melt the sherbet then add the thickener so that it doesn't melt as fast. Cook #2 further stated there were no guidelines in the kitchen for preparing pureed items and that the cooks determine the consistency based on food type and how… | 2020-09-01 |
| 51 | 51 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 880 | F | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the infection control and prevention program included: 1) a timely facility infection control risk assessment, for use in conjunction with the annual review of the facility-wide assessment, to complete an accurate Facility Assessment; 2) the tracking/trending of employee illness; and 3) required elements of the Water Management Program to prevent the growth and spread of Legionella. These failed practices increased the risk of an insufficient Infection Control Program and increased the potential risk for development and transmission of disease and/or infection in all residents (based on a census of 12). Findings: Facility Infection Control Risk Hazards Assessment Review of the Facility Assessment Tool, updated 3/7/19, revealed: We model our infection control and prevention practices to the current CDC (Centers for Disease Control) guidelines and conduct quality monitoring to evaluate practice effectiveness in our facility. Review of the CDC guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 3/15/17, revealed: Performance Monitoring and Feedback: Monitor adherence to infection prevention practices and infection control requirements. During an interview on 4/17/19 at 2:50 pm, the Infection Prevention & Control Registered Nurse (IPCRN) stated a facility infection control risk assessment had not been completed in over a year. He/she stated this was late in getting done. During a second interview on 4/19/19 at 12:40 pm, the IPCRN confirmed the last facility infection control risk assessment was completed in (YEAR)-2017. Review of the most current (Wrangell Medical Center) Infection Control Risk Assessment Tool: Environmental Risks revealed it was dated (YEAR)-17. Review of the facility's policy Infection Prevention and Control Program: SEARHC (Southeast Alaska Regional Health Consortium) Wrangell Medical Center Long Term C… | 2020-09-01 |
| 52 | 52 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2019-04-24 | 947 | F | 0 | 1 | FNNN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure the required nurse aide training, specifically a minimum of 12 hours per year of training, was provided for the assurance of continued competence of nurse aides (#'s 1; 2, and 3) hired by the facility through a travel agency. This failed practice had the potential to affect all residents (based on a census of 12), to receive less than optimal care. Findings: Record review on 4/18/19 at 10:00 am of employee files revealed no documentation of 12 hour annual nurse aide training (to include job specific and dementia training) for 3 certified nurse aides (#'s 1; 2, and 3) out of 3 contracted travel nurse aides. During an interview on 4/18/19 at 10:25 am, the Senior Human Resource (HR) Generalist stated the facility did not have documentation that nurse aide training was completed on an annual basis. He/she stated that the contract agency may keep records of continuing education. He/she stated that the facility did not have a process for ensuring that travel nurse aides had completed a minimum of 12 hours of training, to include dementia training, annually. During an interview on 4/19/19 at 12:37 pm, the Long Term Care (LTC) Care Services Coordinator stated he/she did not have a process to track [MEDICATION NAME] training requirements to ensure competency. During an interview on 4/19/19 at 12:41 pm, the Senior HR Generalist stated that he/she called the contract agency who confirmed they did not maintain documentation that education requirements had been completed. The Senior HR Generalist further stated that there was no record that job specific training had been completed for traveling nurse aides who work in the LTC. Travel nurse aides were invited to attend facility offered trainings if staffing and/or time allowed. No additional documentation that travel nurse aides had received the required minimum of 12 hours of training including dementia training were provid… | 2020-09-01 |
| 53 | 53 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 552 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide medication education to 1 resident (#11) out of 4 residents observed receiving medication. This failed practice inhibited the resident's right to be informed of his/her medication regimen and treatment. Findings: Review of the most recent MDS (Minimum date Set) assessment, a quarterly assessment dated [DATE], revealed Resident #11 was coded as having minimal difficulty hearing; clear speech; ability to make self understood; and usually understands others. During an observation on 4/26/18 at 8:55 am, Licensed Nurse (LN) #2 administered Resident #11's morning medication. Resident #11 asked LN #2 three different times, What are these pills? LN #2 replied each time by saying, It's your morning meds. LN #2 did not offer to explain the medications to the Resident during medication administration. During an interview on 4/26/18 at 3:00 pm, LN #2 was asked what the process was when a resident asked about medications he/she was taking. In response, the LN stated, I'll just sit down and talk to them about it. When asked about the morning medication pass on 4/26/18 with Resident #11, LN #2 stated he/she should have taken the opportunity to explain the medications to him/her. Review of Wrangell Medical Center's Resident's Bill of Rights, undated, reveals, Resident has the right to participate in the development and implementation of his or her person-centered plan of care, including to identify individuals or roles to be included in the planning process; to request meetings and the right to request revisions to the plan of care; to identify the expected goals and outcomes of care; and to identify the type, amount, frequency, and duration of care, among other factors. | 2020-09-01 |
| 54 | 54 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 554 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct appropriate interdisciplinary team (IDT) assessments on 1 resident (#7) out of 8 sampled residents to determine if resident was capable of appropriately administering his/her own medication. This failed practice places all residents at risk for improper self-administration; more specifically, the possibility of over medicating or omitting medications ordered by a physician. Findings: Record review on 4/23-27/18, revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #7 was coded as having a Brief Interview for Mental Status score of 15 (a score of 13-15 determines mental status is intact). Observation on 4/24/18 at 12:06 pm, revealed Resident #7 had an unsecured bottle of multivitamins with an easy-open lid on his/her bedside table. During an interview on 4/24/18 at 12:06 pm, Resident #7 stated he/she took the vitamins daily without notifying any staff and further stated he/she has not taken a vitamin for that day. During an interview on 4/27/18 10:00 am, Licensed Nurse (LN) #2 stated if a resident wanted to self-administer medication, the LN on duty would call the doctor, for an order. Next the nurse would complete a self-administration form and place in chart. During an interview on 4/24/18 at 11:19 am, LN #1 stated, If a Resident requests to self-administer medication, the RN completes the Self-Administration Assessment and puts it in the chart. When asked if the IDT is involved in any way to complete the assessment, LN #1 said, No, only the nurse does them. Review of Resident #7's Medication Administration Record [REDACTED]. Review of Resident #7's medical record did not reveal any self-administration assessment documentation for the ordered multivitamin. Further review of the medic… | 2020-09-01 |
| 55 | 55 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 576 | C | 0 | 1 | O8F911 | Based on interview and record review the facility failed to ensure resident mail was delivered to the facility on Saturdays. This failed practice affected all residents in the facility (based on a census of 10) and denied residents access to mail on Saturdays and delayed receipt of mail until the following Monday. Findings: During an interview with the Resident Group Council on 4/25/18 at 2:06 pm, Resident #s 1; 6; 7; 10 & 11 unanimously concurred there is no mail delivery on Saturday, only Monday through Friday. During an interview on 4/27/18 at 2:10 pm, the facility Purchasing Agent (PA) confirmed she is responsible for getting the resident's mail from the Post Office. The PA further disclosed mail is retrieved from the Post Office Monday through Friday only because no one is trained to get the mail. The Resident mail is mixed in with the facility business mail. Review of Resident Bill of Rights provided by the facility stated Residents had a right to access their mail. Review of the facility policies table of contents did not reveal a policy for resident mail. | 2020-09-01 |
| 56 | 56 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 578 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1) 2 residents #'s (3 & 6) out of 8 sampled residents had been offered an opportunity to develop advanced directives, and 2) the facility had a policy to implement Advanced Directives. This failed practice denied the residents (and/or their representatives) the right to choose and make end of life medical decisions and placed the residents at risk for receiving unwanted or unnecessary care. Findings: Resident #3 Record review from 4/23-27/18, revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of the medical record revealed no advance directive declaration or information had been given to the resident or their representative. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as having a Brief Interview for Mental Status score of 11 (a score of 8-12 determines mental status is moderately impaired). During an interview on 4/25/18 at 11:02 am, the LTC Social Worker (SW) revealed she had not given advanced directive information to Resident #3. She further disclosed the Office of Public Advocacy (OPA) guardian would have been responsible for advanced directive information. Review of a letter dated 4/25/18, from the OPA guardian stated the Office of Public Advocacy is essentially unable to make end of life decisions for a client. Resident #6 Record review from 4/23-27/18, revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of the medical record revealed no advance directive declaration or that information had been given to the resident or their representative. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as having a Brief Interview for Mental Status score of 14 … | 2020-09-01 |
| 57 | 57 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 585 | C | 0 | 1 | O8F911 | Based on record review and interview the facility failed to ensure the grievance policy included all necessary components. Specifically, the grievance policy did not address: 1) all the processes for written grievance decision; and 2) immediately reporting all alleged violations involving neglect and/or abuse, to the administrator, reporting which is required by state law. This failed practice placed all residents (based on a census of 10) at risk of not receiving feedback for grievances filed with the facility and placed them at risk for potential abuse and/or neglect from unreported allegations. Findings: Grievance Policy Review of the facility policy provided on 4/24/18, titled Grievance Policy Date of Revision 3/2017, revealed the following elements were not addressed in the policy: 1) Written grievances decisions include all required information; and 2) Immediately reporting certain allegations as required. During an interview on 4/27/18 at 3:17 pm, the Grievance Officer confirmed the policy did not contain the complete information. | 2020-09-01 |
| 58 | 58 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 600 | D | 0 | 1 | O8F911 | Based on record review and interviews the facility failed to ensure 1 resident (#10), out of 8 sampled residents, was free from verbal abuse during cares. This failed practice placed the resident at risk for further mistreatment, undo stress/suffering and a less than optimal psychosocial environment. Findings: Record review on 4/23-27/18, of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and requires mechanical lift (machine used to move a resident), using 2 staff members for transfers. During an interview on 4/25/18 at 1:28 pm, Resident #10 stated that approximately a week ago CNA #3 was helping him/her, slipped, and caused the bar of the mechanical lift to hit the area above the Resident's right eye. The Resident had requested CNA #4 to help him/her instead. The Resident further stated that CNA #3 got frustrated, took off his/her gloves, threw them in the trash can and in a raised voice said, I am never going to help you again. The Resident further stated soon after this, a LN (licensed nurse) asked CNA #3 to help get Resident #10 into bed. Resident #10 stated he/she saw CNA #3 whisper in the LN's ear and left the area. After this, the LN obtained another CNA to help the Resident that day. Resident #10 stated this event made him/her feel like CNA #3 did not want to work with him/her. During an interview on 4/27/18 10:30 am, the Chief Nursing Officer (CNO) stated she was informed that Resident #10's head was bumped by the mechanical lift and the Resident requested a different CN[NAME] She further stated it was her understanding that CNA #3 removed his/her gloves and stated he/she wasn't going to help anymore. When asked about the manner in which CNA #3 spoke to the Resident, the CNO stated she was unaware that CNA #3 spoke to Resident #10 in a raised voice. When the Surveyor asked if the CNO felt the incident of how the staff spoke the Resident was a reportable incident, CNO replied, I understand it's reportable if there was a bump or bruise. After surveyor showed the CNO the manda… | 2020-09-01 |
| 59 | 59 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 609 | D | 0 | 1 | O8F911 | Based on record review and interviews the facility failed ensure alleged verbal abuse occurring with 1 resident (#10), out of 8 sampled residents, was reported to the State Survey Agency. This failed practice placed resident at risk for further mistreatment, undo stress/suffering and less than optimal psychosocial environment. Findings: Record review on 4/23-27/18, of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and requires mechanical lift (machine used to move a resident), using 2 staff members for transfers. During an interview on 4/25/18 at 1:28 pm, Resident #10 stated that CNA #3 was helping him/her, slipped, and caused the bar of the mechanical lift to hit the area above the Resident's right eye. The Resident had requested CNA #4 to help him/her instead. The Resident further stated that CNA #3 got frustrated, took off his/her gloves, threw them in the trash can and in a raised voice said, I am never going to help you again. Furthermore, the Resident stated a separate event occurred when a Licensed Nurse (LN) asked CNA #3 to help get Resident #10 into bed. Resident #10 stated he/she saw CNA #3 whisper in the LN's ear and left the area. This was immediately followed by the LN obtaining another CNA to help the Resident that day. Resident #10 stated this event made him/her feel like CNA #3 did not want to work with him/her. During an interview on 4/27/18 10:30 am, the Chief Nursing Officer (CNO) stated the process for staff reporting was that the nurse makes a report, writes up the incident, and then provides the report to the CNO. The CNO further explained she has 5 days to do an investigation and report to state. The CNO stated she was informed that Resident #10's head was bumped by the mechanical lift and the Resident requested a different CN[NAME] She continued to state it was her understanding that CNA #3 removed his/her gloves and stated he/she wasn't going to help anymore. When asked about the manner in which CNA #3 spoke to the Resident, the CNO stated she was unaware th… | 2020-09-01 |
| 60 | 60 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 640 | F | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the MDS (Minimum Data Set, a federally mandated assessment) for 5 residents (#s 1; 3; 6; 9; and 10) out of a census of 10 and 1 closed record (resident #5), were transmitted within 14 days after completion. This failed practice placed all residents at risk for less than optimal care or lack of adequate care to meet their individual needs. Findings: Record review on 4/26/18, revealed Resident #1's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #3's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #5's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #6's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident #9's MDS assessment dated [DATE] was not transmitted. Record review on 4/26/18, revealed Resident # 10's MDS assessment dated [DATE] was not transmitted. An interview on 4/26/18 at 2:37 pm, Licensed Nurse (LN) # 3 stated no staff in the facility have transmittal ability/access for sending MDS information as required. The LN confirmed the MDS information has not been submitted for any resident. During an interview on 4/26/18 at 2:50 pm, with the Chief Nursing Officer confirmed no facility staff have the ability to transmit the MDS data as required. | 2020-09-01 |
| 61 | 61 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 642 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a MDS (Minimum Data Set) assessment was completed accurately in accordance with standards set forth by Center for Medicare and Medicaid Services (CMS). Specifically, the facility failed to review five subsections of the MDS for the full 7-day look back period for 1 resident (#10) out of 8 sampled residents. This failed practice placed the resident at risk for improper care planning and denied the resident an accurate assessment of his or her current health care status. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. He/She has a history of bilateral [MEDICAL CONDITION] that left her wheelchair bound. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed Assessment Reference Date (ARD) refers to the last day of the observation (or 'look back') period that the assessment covers for the resident .Most of the MDS (Minimum Data Set) 3.0 items have a 7-day look back period. Review of the Long-Term care Facility Resident Assessment Instrument 3.0 User manual, dated 10/2017, revealed the following sections required a 7-day look back review: C1310; E0100; E0200; E0500; E0600; E0800; E0900; J1100; J1500; J1800; K0100; K0510; P0100; and P0200. Review of the admission MDS (Minimum Data Set) assessment, dated 10/11/17, revealed the Social Worker signed Sections C and [NAME] as completed on 10/10/2017 under Section Z (a day before the last day of review). Additional review revealed LN#3 signed Sections J, K and P as completed on 10/10/17 under Section Z (a day before the last day of review). During random interviews on 4/25-27/18, LN #3 stated he/she was unable to explain why Sections C, E, J, K and P were signed before the ARD date of 10/11/17. The LN further stated that some sections can be done early. Review of the Long-Term care Facility Resident Assessment Instrument… | 2020-09-01 |
| 62 | 62 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 658 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to follow professional standards for nursing during medication administration for 3 residents (#s 7, 10 and 11) during 4 of 4 observations. This failure to administer medications correctly can result in residents receiving more medication than ordered and/or not taking their medications as prescribed. Findings: Resident #7 Record review on 4/23-27/18, revealed Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation on 4/24/18 at 8:58 am, Licensed Nurse (LN) #1 performed medication administration at Resident #7's bedside. The LN gave Resident #7 his/her [MEDICATION NAME] bottle to self-administer the medication. Resident #7 was observed to self-administer 2 sprays in each nostril. LN #1 did not correct this dosing error or provide education. Observation on 4/24/18 at 12:06 pm, revealed Resident #7 had a bottle of multi vitamins on his/her bedside table. During an interview on 4/24/18 at 12:06 pm, Resident #7 stated he/she took the vitamins daily without notifying any staff. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's medical record revealed no form of self-administration assessment documentation approved by the Interdisciplinary Team (IDT). Resident #10 Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. During an observation on 4/24/18 at 8:10 am, LN #1 performed medication administration with Resident #10. The LN placed a cup of pills next to Resident #10 and walked away without observing Resident #10 taking the mediation. During an observation on 4/25/18 at 7:18 am, LN #1 performed medication administration at Resident #10's bedside. He/she gave Resident #10 his/her [MEDICATION NAME] bottle to self-administer his/her medication: [MEDICATION NAME] 50mcg 1 spray both nares. Resident was observed to self-administer 2 sprays in each nostril. LN #1 did not co… | 2020-09-01 |
| 63 | 63 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 684 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 resident (#1) out of 1 resident with a cardiac pacemaker had necessary care and follow up of the device. This failed practice placed the resident at risk for undiagnosed heart rhythm irregularities, missed device changes or alerts and decreased heart health. Findings: Record review from 4/24-27/18, revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the record revealed an EKG (a graphic record of the heart muscle rhythm) dated (MONTH) 19, (YEAR) with results .paced rhythm (a heart rhythm controlled by an internal pacemaker) . Further review revealed a Medtronic Device Identification card (a card with information for implanted medical device) that showed resident information with implant dates, serial and model numbers of the pacemaker and leads (wires attached to the heart muscle from the pacemaker device) in addition contact numbers for Medtronic were listed. Record review of Resident #1's Multi-Disciplinary Care Plan dated 2/7/18, revealed no documentation of the Residents pacemaker or monitoring of the device or implantation site. During an interview on 4/27/18 at 9:18 am, LN #4 stated he/she did not know of any special monitoring or equipment needed for care of a Resident with a pacemaker and was not aware of what provider or facility would be monitoring the pacemaker. During an interview at 4/27/18 at 11:50 am, Licensed Nurse (LN) #1 stated, he/she was not aware of any Resident who had any devices that would require any special care or monitoring. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she was not aware of any resident in the facility who had a pacemaker. The CNO further stated staff were unaware of a resident with a pacemaker or any care needed for monitoring the device or implant (surgical) site. | 2020-09-01 |
| 64 | 64 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 686 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 resident (#10), out of 8 sampled residents, received the necessary care and services to prevent the development of a pressure ulcer. Failure to identify potential risk for development of, or provide appropriate interventions on a timely basis upon admission, to prevent pressure ulcers, placed resident at an increased risk for developing an avoidable pressure ulcer. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility on 10/2/17 with [DIAGNOSES REDACTED]. Review of admission MDS (Minimum Data Set), dated 10/11/2017, revealed Resident #10 was coded as requiring extensive assistance during bed mobility and locomotion on/off unit. The Resident was coded as being totally dependent during transfers and toileting. Review of Resident #10's Admission Nursing Assessment, dated 10/2/17, revealed no skin assessment completed upon admission. Further review of nursing notes for the month of (MONTH) (YEAR) revealed the first documented skin assessment was completed 10/11/17 which stated .(had) a bath today, and skin was intact. Review of Resident #10 nursing note dated 10/18/1,7 revealed During shift change report I was informed that (Resident #10) has a healed decubitus ulcer to coccyx (tailbone area); during .weekly skin assessment I noted that the ulcer is still there, but healing. Review of Resident #10's Wound Assessment Report dated 10/19/17, revealed a Stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist) pressure ulcer was present on the coccyx. The assessment further revealed the wound was described as: Length 0.20cm, Width 0.20cm, Depth 0.10cm. Picture taken on 10/19/17, by the wound care nurse, revealed an open red area to the coccyx. Review of Resident #10s admission orders [REDACTED]. Review of Resident #10's medical record nursing note dated 10/19/17, revealed has a new bed to assist with coc… | 2020-09-01 |
| 65 | 65 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 689 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure CNA (Certified Nursing Assistant) staff were implementing consistent, safe interventions when conducting Hoyer lift transitions. This deficient practice increased the hazard and risk of falls for one resident (#10), out of 5 residents requiring the use of a mechanical lift, while being transferred from bed to wheelchair. Findings: Record review on 4/23-27/18 of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and required mechanical lift (machine used to move a resident), using 2 staff members for transfers. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed Resident #10 was coded as requiring extensive assistance (resident involved in activity, staff provide weight-bearing support) during bed mobility; transfer; toileting; dressing; and personal hygiene. His/her functional limitation to range of motion in lower extremities was coded as impairment to both sides. Resident #11's mobility device was a wheelchair. During an observation on 4/25/18 at 7:46 am, Certified Nursing Assistant (CNA) #1 used Hoyer lift to assist Resident #10 from his/her bed to his/her wheelchair. As Resident #10 was suspended in the Hoyer, CNA #1 placed the wheelchair under Resident #10, tilted the wheelchair back onto its rear wheels and held the wheelchair in that position as Resident #10 was lowered into the wheelchair. During an interview on 4/25/18, CNA #1 stated he/she always tilts the wheelchair back when the resident is lowered from the Hoyer lift. During an interview on 4/25/18 at 2:12 pm, Resident #10 expressed that he/she does not like the wheelchair being tilted back as it makes him/her feel unsafe and unstable. During an interview on 4/27/18 at 9:31 am, CNA #2 stated the wheelchair should be sideways and never tilted, because there is a risk of injury due to tilting. During an interview on 4/27/… | 2020-09-01 |
| 66 | 66 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 726 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure staff had appropriate competencies and skills necessary to care for 1 resident (#1) of 1 resident with a cardiac pacemaker. This failed practice placed the resident with a pacemaker at risk for receiving less than optimal care from nursing staff. Findings: Record review from 4/24-27/18, revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/24-27/18, of Resident #1's Multi-Disciplinary Care Plan, dated 2/7/18, revealed no documentation of Resident #1's pacemaker or any special care the Resident or the device may require. During an interview at 4/27/18 at 11:50 am, LN #1 stated he/she was not aware of any Resident who had any devices that would require any special care or monitoring. During an interview on 4/27/18 at 9:18 am, Licensed Nurse (LN) #4 stated he/she did not know of any special monitoring or equipment needed for care of Resident #1's pacemaker and was not aware of what provider or facility would be monitoring the pacemaker. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she did not know there was a Resident in the facility who had a pacemaker. The CNO further stated staff did not have any special training on how the pacemaker is monitored, equipment to use, or care of the implant (surgical) site. | 2020-09-01 |
| 67 | 67 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 756 | E | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure: 1) the pharmacist had access to the complete medical record (#9); 2) the pharmacist noted and reported unnecessary medications for two residents (#s 2 and 10); and 3) policies and procedures were developed and maintained for the monthly drug regimen reviews that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. These failed practices placed 1 resident (#9) at risk for ineffective medication management; 2 residents (#s 2 and 10) at risk for receiving unnecessary medication (based on a sample of 8) and placed all residents (based on a census of 10) at risk for delay in review of their current drug regimen reviews. Findings: Resident #9 Record review on 4/24-27/18, revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED].) Review of the Drug Regimen Review (DRR), dated 12/17/17, revealed Resident #9 had a dosage change in (MONTH) (YEAR) to [MEDICATION NAME] 1mg by mouth HS (evening time). Further review of Resident #9's medical record revealed multiple month behavior logs and AIMS assessments (Abnormal Involuntary Movement Scale-a screening tool used to identify movements in people taking antipsychotic medications) in the medical record from (MONTH) (YEAR) to (MONTH) (YEAR). Review of monthly DRR in Resident #9's medical record from (MONTH) (YEAR) to (MONTH) (YEAR), revealed no comments by the Pharmacist to verify review of AIMS assessments and behavior logs. During an interview on 4/27/18 at 11:00 am, the Pharmacist stated AIMS assessments and behavior logs were not looked at for DRR. The Pharmacist further stated they do not have access to those documents for review. These documents should be part of the Pharmacist review for Residents taking medications that sta… | 2020-09-01 |
| 68 | 68 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 757 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 resident's (#10), out of 8 sampled residents, drug regimen was free from unnecessary drugs. The failed practice exposed the resident to 2 drugs without adequate indications for their use or continued use. As a result, this placed the resident at risk for adverse reactions and tolerance to drug therapy. Findings: Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. Medication: [MEDICATION NAME] Review of Resident #10's medical record revealed physician's orders [REDACTED]. Record review of physician notes, dated 10/7/17 to 1/5/18, revealed multiple notes indicating treatment with [MEDICATION NAME] ineffective: -10/7/17 - .continues (to) complain of (body) pain even though we started (Resident #10) on [MEDICATION NAME] to treat what seemed like active [MEDICATION NAME]. -10/31/17 - .continuing to complain of (pain) which is related to .shingles and is now being treated with [MEDICATION NAME]. -12/5/17 - .continues to have chronic pain related to the open shingles [MEDICAL CONDITION] . -12/19/17 - chronic shingles .with suboptimal response to [MEDICATION NAME] .complains of chronic pain .as well as pain over (Resident #10's) [MEDICAL CONDITION] for which we have not made much progress .increase (Resident's) dose of [MEDICATION NAME] to 1000mg (twice a day) . -1/5/18 - Patient still complaining of 10 out of 10 pain .today I cultured the open wound on (the Resident) .if this does not grow any [MEDICAL CONDITION] I will discontinue oral [MEDICAL CONDITION] medication . Review of Resident #10's lab work, since admission, revealed the Physician ordered a [MEDICAL CONDITION] culture on 1/5/18 which had negative results for [MEDICAL CONDITION] Simplex Virus (HSV). Further review of the resident's medical record revealed [REDACTED]. Review of Resident #10's monthly Drug Regimen Reveiws revealed no review in (MONTH) (YEAR). During an int… | 2020-09-01 |
| 69 | 69 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 759 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure medication error rate was less than 5%. Specifically, 2 residents (#s 7 and 10), out of 4 residents observed receiving medications, were free of medication errors. This failed practice placed the residents at risk for over medication. Findings: Resident #7 Record review on 4/23-27/18, revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #7's physician orders [REDACTED]. During an observation on 4/24/18 at 8:58 am, Licensed Nurse (LN) #1 performed medication administration at Resident #7's bedside. The LN gave Resident #7 his/her [MEDICATION NAME] bottle to self-administer the medication. Resident #7 was observed to self-administer 2 sprays in each nostril. LN #1 did not correct this dosing error or provide education. Resident #10 Record review on 4/23-27/18, revealed Resident #10 was admitted to facility with [DIAGNOSES REDACTED]. Review of Resident #10's physician orders [REDACTED]. During an observation on 4/25/18 at 7:18 am, LN #1 performed medication administration at Resident #10's bedside. The LN gave Resident #10 his/her [MEDICATION NAME] bottle to self-administer the medication. Resident was observed to self-administer 2 sprays in each nostril. LN #1 did not correct this dosing error or provide education. During an interview on 4/27/18 at 2:00pm, LN #1 confirmed he/she did see both Residents dispense 2 sprays of [MEDICATION NAME] in each nostril and that he/she did not correct the dosing error or provide education on correct dosing. | 2020-09-01 |
| 70 | 70 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 800 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to provide 2 residents (#s 1 and 10) out of 8 sampled residents the appropriate diet as ordered by the physician. This failed practice placed the residents at risk for inadequate nutritional intake and risk for medical complications. Findings: Resident #1 Record review on 4/23-27/18, revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Review of Resident #1's physician orders [REDACTED]. During an observation on 4/24/18 at 12:00 pm, the Cook #1 prepared and served Resident #1 a mechanical soft diet. This preparation was completed without the use of a diet card. A dietary sticker was placed on the plate container lid once completed and placed on cart for delivery. During an observation on 4/24/18 at 12:35 pm, Resident #1 stated she didn't like the way the food was chopped up and pushed the meal away, refusing to eat it. During an interview on 4/27/18 at 2:00 pm, the Cook #1 could not remember what type of diet he/she prepared and served Resident #1 on 4/24/18. Resident #10 Records review on 4/23-27/18, revealed Resident #10 was admitted with [DIAGNOSES REDACTED]. Review of Resident #10's physician orders [REDACTED]. Review of definitions from Simplified Diet Manual 11th Edition, published 2012, reveals NAS diets are used for residents with [MEDICAL CONDITION] who are at risk for high blood pressure and [MEDICAL CONDITION]. Consistent carb diets are used for residents with diabetes. Review of Wrangell Medical Center's dietary menu for 4/24/18, reveals NAS diet means no pickle and consistent carb diet means fruit instead of cookie. During an observation on 4/24/18 at 12:00 pm, the Cook #1 prepared and served Resident #10 a regular diet that included a pickle and a cookie. This preparation was completed without the use of a diet card. A dietary sticker was placed on the plate container lid once completed and placed on cart for delivery. During an interview on 4/27/18 a… | 2020-09-01 |
| 71 | 71 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 812 | F | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review of central kitchen area, the facility failed to prepare and/or store food under proper sanitation and food handling practices. This failed practice placed all residents (based on a census of 10) at risk for foodborne illness and communicable disease. Findings: Food Preparation During a 33 minute observation on [DATE] at 4:57 pm, Cook #2 was observed during dinner preparation. The Cook's hair was exposed (coming out of) hair net; did not wear a mask during food prep and plating despite coughing repeatedly over food; handled food with ungloved hand(s); licked food off of his/her ungloved hand while preparing pureed spinach and resumed food prep without washing hands; and wiped nose with ungloved hand and continued to complete food prep without washing her hands. During a 22 minute observation on [DATE] at 12:10 pm, Cook #1 prepared and plated meals without gloves on, scooping mashed potatoes from a pot using a metal scooper. Next, Cook #1 tossed the scooper into the pot of mashed potatoes and later retrieved the scooper with an ungloved hand, handle of scooper was covered in mashed potatoes, and continued to plate meals with scooper. Food Storage An observation of the central kitchen on [DATE] at 4:57 pm, revealed expired food/damaged containers in freezers: plastic bag labeled turkey carcass ,[DATE] that was covered in ice crystals; plastic container labeled bean soup ,[DATE] lid and lip of container itself was broken exposing food to the environment; 1.5 quart carton of sherbet ice cream, opened with no date, side of carton damaged exposing ice cream to the environment; plastic bag labeled chicken enchilada filling [DATE] food covered in ice crystals; plastic bag labeled ham ,[DATE] covered in ice crystals; 2 - 18oz bags of white tortilla shells expiration date 10 APR (YEAR). Observation of the central kitchen refrigerator on [DATE] at 4:57 pm, contained: 1 - 17.8oz opened bag of white tortil… | 2020-09-01 |
| 72 | 72 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 838 | D | 0 | 1 | O8F911 | Based on record review and interview the facility failed to ensure the facility assessment identified the clinical needs of residents with pacemakers in the facility, as well as, competency opportunities for staff caring for the pacemakers. This failed practice placed 1 resident (#1) out of 1 Resident with a pacemaker at risk for not having necessary cardiac monitoring equipment and care. Findings: Review of the facility assessment on 4/24-27/18, revealed the facility assessment had not identified Resident #1 who had a cardiac pacemaker who needed special monitoring equipment and care. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she did not know there was a Resident in the facility who had a pacemaker. The CNO further disclosed the resident was not identified in the facility assessment. In addition, the assessment did not identify any special training or care the Resident would require. | 2020-09-01 |
| 73 | 73 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 842 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain accurate and complete medical records. Specifically, the facility failed to provide documentation for 1 resident (#5) out of 1 record reviewed for distribution of belongings after death. This failed practice placed the resident's estate at risk for misappropriation of the resident's belongings. Findings: Record review on ,[DATE]-,[DATE], revealed Resident #5 was admitted to the facility on [DATE] and expired on [DATE]. Further review revealed there was no documentation of the Resident's belongings disposition after death and no signature documenting disposition on the facility list of Resident #5's belongings. During an interview on [DATE] at 2:50 pm, the Chief Nursing Officer confirmed the Resident's belongings had not been signed for and there was no documentation of disbursement of the Resident's belongings after death. | 2020-09-01 |
| 74 | 74 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 865 | F | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the QAPI (Quality Assurance Performance Improvement), used to identify and implement change for improvement, and had identified areas that had been or should have been identified. Specifically , the QAPI committed failed to ensure: 1) the need for an updated facility assessment to include 1 resident #1 who needed specialized care; 2) identify late transmissions of MDS (material data set-a federal mandated assessment); 3) identify the lack of antibiotic stewardship program. (based on a census of 10). Without identifying or adequately addressing areas of quality deficiencies systematic correction could not be achieved and/or maintained. Failure to identify systemic processes for improvement had the potential to place all residents at risk for poor outcomes. Findings: Review of the QAPI Plan revised 4/2018, revealed .Improve the safety of the healthcare system and work processes; Identify indicators of quality related to structure, process and outcomes of patient care; .design or redesign care processes . Facility assessment Review of the facility assessment on 4/24-27/18, revealed the facility assessment had not identified Resident #1 who had a cardiac pacemaker who needed special monitoring equipment and care. Record review revealed Resident #1 had been admitted to the facility on [DATE] with an implanted cardiac pacemaker. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she did not know there was a Resident in the facility who had a pacemaker. The CNO stated the pacemaker should have been in the facility assessment to ensure special training or care required of staff. MDS Transmittals Record review from 4/24-27/18, revealed Resident #'s 1; 3; 5; 6; 9; and 10 had MDS assessments completed but not transmitted. Refer to Citation 640. During an interview on 4/27/18 at 9:29 am, the Quality Director (QD) revealed, she did not know the MDS assessment… | 2020-09-01 |
| 75 | 75 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 880 | F | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation the facility failed to ensure the infection prevention and control committee had reviewed the infection control plan and policies/procedures on an annual basis, developed and implemented a program specific to the facility assessment, and include required infection prevention and control plan elements. In addition a medical device was not maintained in a clean manner for 1 Resident (#10) out of 1 resident reviewed for indwelling urinary catheter. Specifically the facility failed to; 1. Conduct an annual review of its Infection Prevention Control Plan and Infection control policies 2. Identify the criteria used for infection surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility, identify what infections, when and to whom the infections should be reported to and document antibiotic process, outcome surveillance and action plans 3. Establish and implement a water management program that included policies and procedures, specific for the facility to mitigate the risk of growth and spread of Legionella and other opportunistic water borne pathogens in the facility's water system 4. Prevent an indwelling urinary catheter bag from resting on the floor These failed practices increased the risk for development and transmission of disease and infection and increased the risk of multidrug resistance in a vulnerable population of all residents based on a current census of 10. Findings: 1) Annual Review of Infection Prevention Control Program and Policies Review of the facility's policy Infection Prevention and Control Program with a revision date of 6/2016, revealed the policy had not been reviewed for 22 months. Additionally randomly reviewed infection control policies revealed last reviewed dates of: - Glucometer Cleaning, revision date 3/2016 - Hospital Acquired Infections, revision date 6/15/2016 - Hand Washing, revision date 6/2016… | 2020-09-01 |
| 76 | 76 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 881 | F | 0 | 1 | O8F911 | Based on record review and interview the facility failed to implement a facility specific antibiotic stewardship program to monitor the use of antibiotics. Failure to monitor the appropriate use of antibiotics had the potential to increase antibiotic resistance among all residents (census of 10). Findings: Record review on 4/25/18 at 10:00 am, revealed a draft antibiotic stewardship policy that was not implemented at the time of review. During an interview on 4/27/18 at 12:18 pm, the Infection Control Preventionist stated the antibiotic stewardship policy was in draft and had not been implemented yet and she was not checking on Loeb (a standard used for initiation of antibiotics) criteria at this time. | 2020-09-01 |
| 77 | 77 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2017-06-09 | 328 | D | 0 | 1 | 8G9Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure humidified oxygen was maintained for 1 resident (#2) of 1 sampled resident who received oxygen. This failed practice failed to ensure the use of humidified oxygen to relive dryness of nasal passages and maintain resident comfort. Findings: Resident #2 Record review on 6/6-9/17, revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 6/7/17, of Resident#2's most current care plan revealed, Oxygen at 2L via nasal cannula , round hourly when resident is in bed. Specifically check her for oxygen being on at 2L via NC (nasal cannula) . Observation on 6/7/17, at 10:10 am revealed the humidifier bottle attached to the wall oxygen was near empty. The oxygen delivery was set at 2L, via nasal cannula. Observation on 6/7/17, at 3:10 pm revealed the humidifier bottle attached to the wall oxygen was near empty. The oxygen delivery was set at 2L, via nasal cannula. Observation on 6/8/17, at 7:38 am revealed the humidifier bottle attached to the wall oxygen was empty. The oxygen delivery was set at 2L, via nasal cannula. Observation on 6/8/17, at 1:30 pm revealed the humidifier bottle attached to the wall oxygen was full of water and bubbling. The oxygen delivery was set at 2L, via nasal cannula. During an interview on 6/9/17, at 8:45 am, RN #1 stated the oxygen humidification bottles were all staffs responsibility to fill daily. In addition, the purpose of oxygen humidification is to prevent nasal dryness and provide resident comfort. | 2020-09-01 |
| 78 | 78 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2017-06-09 | 514 | C | 0 | 1 | 8G9Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain accurate and complete medical records. Specifically, the facility failed to: 1) document the indication of use for medications in the residents' medical record for 6 residents (#s 1; 2; 3; 4; 5 and 7) out of 8 sampled residents whose medical records were reviewed, and 2) provide documentation for one Resident's (#6) distribution of belongings after death. These failed practices placed the residents at risk for 1) receiving inappropriate medications and 2) misappropriation of the resident's belongings. Findings: Indications for Use of Medications: Resident #1 Record review from ,[DATE]-,[DATE] revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current medication administration record (MAR) and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #2 Record review on ,[DATE]-,[DATE] revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #3 Record review from ,[DATE]-,[DATE] revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail revealed no documentation of [DIAGNOSES REDACTED]. Resident #4 Record review from ,[DATE]-,[DATE] revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail revealed no documentation of [DIAGNOSES REDACTED]. Resident #5 Record review on ,[DATE]-,[DATE] revealed Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the most current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #7 Record review on ,[DATE]-,[DATE] revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most current… | 2020-09-01 |
| 79 | 79 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2019-01-08 | 638 | D | 1 | 0 | MBVY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to complete a quarterly MDS (Minimum Data Set, a federally required nursing assessment) assessment for 1 resident (#1) of 3 sampled residents whose MDS assessments were reviewed. This failed practice created a potential for incomplete and/or inaccurate care planning. Findings: Record review on 1/7-8/19 revealed Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessments revealed the following: an admission assessment dated [DATE], a quarterly assessment dated [DATE], a discharge assessment with return anticipated dated 12/24/18 and an Entry tracking record dated 12/28/18. A quarterly assessment, due by 9/13/18, was missing. During an interview on 1/8/19 at 11:56 am, MDS Coordinator (MDSC) #2 stated he/she had not done the quarterly assessment. During an interview on 1/9/19 at 2:13 pm, MDSC #1 stated there are 3 MDS coordinators. Each coordinator is responsible for their assigned residents. A hand written calendar is used to document when MDS assessments are due for each resident. | 2020-09-01 |
| 80 | 80 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-03-15 | 585 | F | 1 | 0 | M2PE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview, the facility failed to ensure a method for grievances to be filed anonymously and/or verbally. This failed practice had the potential to affect all residents in the facility (based on a census of 48) and denied residents and interested parties the ability to exercise their rights by filing grievances anonymously or to have their concerns recieved verbally. Findings: Observation on 3/14/18 at 9:00-9:15 am of the facility dining rooms, revealed a large monitor screen that flashed information about the facility rules and activities. The information included the residents right to file a grievance and the grievances officer information was listed. In addition, the screen included information about the residents and/or their families right to file a grievance verbally and anonymously. There was no information on the screen, or on the bulletin board, located across the room, that instructed people on how to file a grievance anonymously. There were no forms, used for filing complaints in the area, nor was there an obvious secure place to put the forms once they had been filled out. Anonymous/ Verbal Grievances Resident #2 Record review on 3/14-15/18 revealed Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. The Resident was receiving MS ([MEDICATION NAME] sulfate) via a PCA (patient controlled [MEDICATION NAME]) for pain management. During an interview on 3/14/18 at 10:50 am, Resident #2's Family Member stated he/she had expressed several concerns to facility staff about the care Resident #2 had been receiving. When asked if he/she had ever filed a grievance or complaint with the facility, the Family Member stated he/she approached the Shift Supervisor about it a couple weeks ago, and was handed a bunch of forms to fill out. The Family Member did not want to have to fill out forms and stated he/she had a stack of these forms. During the interview the Family Member stated he/she… | 2020-09-01 |
| 81 | 81 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-03-15 | 677 | D | 1 | 0 | M2PE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, and interview the facility failed to ensure activities of daily living (ADL care such as hygiene and skin care) were offered and/or provided to 1 resident (#2) out of 4 residents observed receiving care. This failed practice placed the resident at risk for poor outcomes from lack of hygiene and a risk for infection and/or poor skin conditions and a decreased feeling of self-worth. Findings: Record review on 3/14-15/18 revealed Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #2's Care Plan, dated 2/19/18, revealed Can't move around well on my own. lose control of by bladder and/or bowels. Sometimes get confused or can't remember things. don't receive the proper nutrition. have an existing skin injury. The approach included I need my aides to-help me with hygiene and general skin care . Grooming During an observation on 3/14/18 of incontinence care being provided to Resident #2 at 6:20 am and 10:30 am, and repositioning of the Resident at 8:00 am and 9:10 am, the Resident was not offered the opportunity to wash his/her face and hands nor was oral care offered or provided. In addition, the Resident had significant facial hair growth. During an interview on 3/14/18 at 10:40 am, Resident #2's family member stated the Resident had not had his/her teeth brushed. The Family member showed the surveyor two travel sized tubes of toothpaste, kept in the bathroom, one of which was slightly used, and stated Resident #2 had the same tubes of tooth paste since admission nearly 3 weeks ago. Closer examination of the tooth brush revealed it was dry. During an observation on 3/14/18 at 10:50 am, when Certified Nursing Assistant (CNA) #2 entered Resident #2's room, the Family Member stated to the CNA he/she had told evening shift staff the Resident needed to be shaved, the CNA replied I didn't get that message. The CNA then offered to shave the Resident. Observation on 3/15/18 at 8:4… | 2020-09-01 |
| 82 | 82 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-03-15 | 686 | D | 1 | 0 | M2PE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > . Based on record review, observation, and interviews the facility failed to ensure measures to prevent a pressure injury for 1 resident ( #1) out of 2 residents reviewed with pressure injuries, were implemented. This failed practice placed the resident at risk for worsening pressure injuries. findings: Record review on 3/14-15/18 revealed Resident #1 was admitted to the facility for comfort care (care for someone with a terminal illness) and had [DIAGNOSES REDACTED]. The Resident was admitted with a pressure injury to the right hip, a deep tissue injury to the right metatarsal head (on the foot), and a reddened area to the left heel. Review of the Wound/Skin Care Orders/ TAR (Treatment Administration Record), (MONTH) (YEAR), revealed Wound Number:3 Dx. Wound [MEDICATION NAME] (prevention) Location: L (left) Heel. the treatment was a Foam Dressing Allevyan heel. Review of the Resident's Care Plan, dated 12/14/17, revealed I have a skin injury .sometimes get confused or can't remember things, can't move around well on my own . The Approach included I need my aides to-help me reposition at least every 1-2 hours while I'm in bed .elevate my heels in bed. Observation on 3/14/18 at 12:24 pm, Resident #3 was observed lying supine on an air mattress. The Resident's heels were resting directly on the mattress. Observation on 3/14/18 at 12:50-1:00 pm, Certified Nursing Assistant (CNA) #1 and Licensed Nurse #1 repositioned Resident #1 in the bed. Both Resident's feet were lying directly on the bed and the heels were not elevated on a pillow to be off the bed. The Resident began to cry out that his/her left leg hurt. During an interview on 3/14/18 at 1:03 pm, when asked about Resident #1's heels, CNA #2 stated the Resident had sores on both his/her heels. When asked if there were any skin precautions for the heels, the CNA replied Resident #1 had a pink dressing to his/her left heel to protect it and the staff place a pillow between the Resident's leg… | 2020-09-01 |
| 83 | 83 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 166 | C | 0 | 1 | NLCD11 | Based on observations, admission packet review, and interview, the facility failed to ensure residents (based on a census of 39) had been provided with the name of the grievance officer. This failed practice denied residents and their families and/or interested parties, needed information on who to file a grievance with. Findings: Random observations during the survey on 6/19-22/17 revealed the name of the Grievance Officer was not posted on the wall in the common areas. Review on 6/19/17 of the admission packet provided to Resident's upon admission revealed the name of the Grievance Officer was not listed with the contact information. During a group interview on 6/21/17 at 11:00 am, all 5 Residents (#2; #16; #17; #18; and #19) stated they did not know who the Grievance Officer was. Review on 6/21/17 at 3:00 pm of Resident #17's admission packet, with the Resident, revealed the information did not contain the Grievance Officer's name. | 2020-09-01 |
| 84 | 84 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 205 | D | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure bed hold information was provided to 1 resident (#11) out of 2 residents reviewed for emergency transfers. The failure to provide information regarding the bed hold policy, denied the resident and/or family members current information about their right to return to the facility. Findings: Record review on 6/22/17 revealed Resident #11 had an unplanned transfer to the hospital on [DATE]. There was no information in the medical record indicating the Resident and/or Resident's family member(s) were provided information about their right to return to the facility after the transfer. During an interview on 6/22/17 at 4:05 pm, the Director of Nursing was unable to produce documentation the Resident and/or Resident's family was notified of the facility's bed hold policy. | 2020-09-01 |
| 85 | 85 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 221 | D | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and protocol review the facility failed to ensure 1 resident (#3) out of 7 sampled residents was free from physical restraints. Specifically, the facility failed to ensure a transfer belt was not used as a restraint. This failed practice had the potential to cause a decrease in self-worth and self-esteem related to respect and dignity of the individual. Findings: Resident #3 Record review from 6/19-22/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of the Resident Daily Care Plan (RDCP) dated 6/7/17 and updated on 6/14/17 revealed no mention of a transfer belt on the care plan. Observation on 6/19/17 at 8:30 am, revealed Resident #3 sitting in the dining area at the table with a bright colored orange belt wrapped around the back of his/her wheelchair and buckled at his/her waist. The back of the belt had writing on it from a black marker that said Do Not Remove. Observation on 6/19/17 at 11:55 am revealed Certified Nursing Assistant (CNA) #1 assisted Resident #3 from the bed to the wheelchair using a white cloth transfer belt. Once in the wheelchair, CNA #1 wrapped a bright orange belt around the Resident and the back of the chair. When asked why the belt was wrapped around the wheelchair, CNA #1 stated To keep (him/her) upright in the chair. Observation on 6/19/17 at 12:05 pm, revealed Resident #3 at the dining table in the common room. The bright orange belt was wrapped around the Resident's wheelchair and buckled at the waist. During an interview on 6/19/17 at 1:00 pm, Resident #3's family member was in the Resident's room. When asked about the belt around the wheelchair, the family member stated It is for positioning, to keep (him/her) from falling over. During an interview on 6/19/17 at 1:02 pm, Resident #3 stated he/she could not release the buckle on the orange transfer belt. Observation on 6/19/17 at 1:25 pm revealed Occupational Therapist #1… | 2020-09-01 |
| 86 | 86 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 242 | E | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 1 resident (#1) was allowed to go to bed as he/she wished and failed to ensure 9 residents (#s 1; 2; 6; 12; 13; 14; 15; 16; and 17), out of 39 residents residing in the facility, were able to dine in a timely manner after the meal trays had arrived. This failed practice denied the residents the right to exercise their right to make choices about their schedule and accommodate their needs and placed residents at risk for poor feelings of self-worth and psychological harm. Findings: Resident Choice Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility for rehabilitation. The Resident's [DIAGNOSES REDACTED]. The Resident needed extensive assistance for transfers with 2 staff and used a wheelchair for mobility. During an observation on 6/20/17 at 11:45 am, Resident #1 was brought back to the unit dining room after completing occupational and physical therapy for the past 2 1/2 hours. During the observation Resident #1 told Certified Nursing Assistant (CNA) #4 he/she was tired and wanted to lay down in bed for a little bit. The CNA replied to the Resident, If you lay down you'll have to get right back up. You only have 45 minutes until lunch. Why don't you wait until after lunch? CNA #4 spent several minutes explaining to the Resident why he/she could not take a nap just yet. The CNA then offered Resident #1 a glass of water. The Resident continued to sit at the dining room table until lunch was served at 1:00 pm, over an hour after he/she had requested to lie down. Review on 6/22/17 of the facility's Reisdents handbook provided to the residents at amittance revealed, .As a Resident, you have the Right: .To receive services that meet your individual needs and preferences . Delay in Meal Service South Side During an observation in the south dining room on 6/19/17 at 12:15 pm Resident #s 1; 6; 12; and 13 were observed sitting in the dining room wa… | 2020-09-01 |
| 87 | 87 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 281 | D | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident care and services were provided in accordance with professional standards for 1 Resident (#4) out of 7 residents whose medical care was reviewed. Specifically, the facility failed to alert the physician if the Resident experienced 2 blood sugar readings above 200mg/dl in a 24 hour period. Failure to provide services according to professional standards of practice placed the Resident at a greater risk of poor outcomes. Findings: Record review from 6/19-22/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review from 6/19-22/17 of Resident #4's electronic medical record (EMR) revealed a physician's orders [REDACTED]. Further review from 6/19-22/17 of Resident #4's EMR dated 6/18/17 revealed entries for the evening blood sugar of 203 mg/dl and bedtime blood sugar of 207 mg/dl. Additional review of the EMR Nursing Notes dated 6/18/17, revealed no additional notations in the nursing notes indicating communication of the two reportable blood sugar levels to the physician. During an interview on 6/20/17 at 7:00 am when asked what do you do when medication administration parameter were not met, LN #1 responded, to notify the MD, document findings in the communication log and notify the nursing supervisor. During an interview on 6/20/17 at 9:25 am Licensed Nurse (LN) #2 states: notify the MD, document findings in the communication log and notify the nursing supervisor when parameters are not met. Record review of the facilities communication log dated 6/18-19/17 revealed no documented communication to the physician of Resident #4's blood sugar results. During an interview on 6/20/17 at 10:00 am, Nursing Supervisor #1 confirmed the MD should have been notified. Review of the Alaska State Nursing Statutes and Regulations, dated (MONTH) 2014, revealed .practice of registered nursing' means the .execution of a medical regimen as prescribed by a… | 2020-09-01 |
| 88 | 88 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 309 | E | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and protocol review the facility failed to ensure 1 resident (#1) received necessary services for: 1) urinary incontinence, 2) pain, and 3) oral care; and 1 resident (#2) received prompt treatment and physician notification after experiencing increased pain after a fall, out of 7 sampled residents reviewed. These failed practices denied residents necessary interventions and services to promote health and well-being and placed them at risk for increased pain and suffering. Findings: Resident #1 Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was at the facility to receive rehabilitation for an anticipated discharge home. The Resident's medication regime included [MEDICATION NAME] 0.4 mg at bedtime (medication used to improve urination); [MEDICATION NAME] 50mg 2 times a day (medication used for [MEDICAL CONDITION] that is used for neuropathic pain); and Tylenol 325mg 2 tablets every 6 hours as needed for pain. 1) Urinary Incontinence Care Review of most recent Minimum Data Set (MDS-a federally required assessment) admission assessment, dated 5/3/17, revealed the Resident required extensive assistance with transfers and was frequently incontinent of bowel and bladder. Review of the Care Area Assessment (CAA), dated 5/9/17, revealed under type of incontinence Resident #1 was Frequently incontinent of bladder and bowel. Continuous observation on 6/20/17 from 7:20 am until 2:00 pm (6 hours and 40 minutes) revealed the Resident was awake, ate breakfast, went to occupational therapy (OT) and physical therapy (PT), and returned to the unit and ate lunch. The Resident was not offered toileting or checked for incontinence during the observation. During an observation on 6/20/17 at 2:00 pm, Certified Nursing Assistant (CNA) #4 and Licensed Nurse (LN) #4 transferred the Resident into bed. The CNA removed the Resident's incontinenc… | 2020-09-01 |
| 89 | 89 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 314 | D | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to prevent a pressure injury for 1 resident (#5) out of 7 sampled residents. The failure to prevent a Stage II pressure injury caused the resident unnecessary pain and resulted in an increased risk for infection, delayed healing, and poor medical outcome. Findings: Resident #5 Record review from 6/19-22/17 revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set-a federally required nursing assessment), an admission assessment dated [DATE], revealed the Resident was coded as having short and long-term memory loss; severely impaired cognitive skills for daily decision making; incontinence of urine; requiring extensive assistance with bed movement and transfers; and at risk for developing pressure injuries. Further review revealed the Resident was coded as not having any pressure injuries. Record review on 6/20-22/17 of Resident #5's Comprehensive Care Plan (CCP) dated 5/8/17, revealed Problem .at risk for skin breakdown related to: decreased mobility, incontinence and diabetes . Further review revealed Braden score (an assessment tool that helps predict pressure injury risk) of 13. A Braden score of 13 represents a moderate risk for skin injury. Review of the Residents Daily Care Plan (RDCP) dated 4/25/17 with updates on 5/18/17, 5/23/17, 6/1/17, 6/8/17, and 6/14/17 revealed, Positioning .float heels when in bed . Review on 6/20/17 at 10:30 am of Resident #5's Admission and Readmission body check dated 5/23/17 revealed no indication of right heel skin injury. Review on 6/20-22/17 of the Certified Nurse Assistant (CNA) charting from 4/25/17 to 6/22/17 under the section, .SKIN OBSERVATION revealed no documentation of the right heel skin injury. Further review revealed no documentation that the Resident's heels were floated. Nursing Notes Review on 6/20-21/17 of Resident #5's nursing notes revealed the follow… | 2020-09-01 |
| 90 | 90 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 315 | D | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review the facility failed to ensure 1 resident (#1), out of 7 sampled residents, urinary incontinence was assessed for participation in an individualized toileting program to improve urinary function. This failed practice placed the resident at risk for diminished feelings of self-worth, reduced quality of life, and for a potentially unsuccessful discharge. Findings: Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was at the facility to receive rehabilitation for an anticipated discharge home. Continuous Observation: Observation on 6/20/17 from 7:20 am until 2:00 pm (6 hours and 40 minutes), revealed the Resident was awake, ate breakfast, went to occupational and physical therapy, returned to the unit and ate lunch. The Resident was not offered toileting or checked for incontinence during the observation. At 2:00 pm, Certified Nursing Assistant (CNA) #4 and Licensed Nurse (LN) #4 transferred the Resident to bed. After the Resident was assisted to bed the CNA checked his/her adult incontinence brief. The brief was heavily saturated with dark foul smelling urine. During an interview on 6/20/17 at 2:10 pm, when asked if he/she was able to feel the urge to void Resident #1 stated I'm not sure. Review of the Nursing Physical Examination for Resident #1, dated 4/26/17, revealed under the GU ([MEDICAL CONDITION]) section Incontinent was circled; the section where the assessing nurse was to mark the type of incontinence was not filled out. Review of the Resident's Daily Care Plan (RDCP), updated 4/26/17, revealed Toileting: Incontinent of bladder. Continent of bowel. Offer toileting in am, before and after meals, prior to rehab, and HS (bedtime) and prn (as needed) . Review of the most recent Minimum Data Set (MDS-a federally required assessment) admission assessment, dated 5/3/17, revealed the Resident required e… | 2020-09-01 |
| 91 | 91 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 329 | D | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to adequately monitor the drug regime for 1 resident (#3) out of 3 sampled residents reviewed for antipsychotic use. Specifically, the facility failed to perform an Abnormal Involuntary Movement Scale (AIMS) upon admission. Failure to adequately assess and review for possible side effects placed the resident at risk for undesirable side effects of an antipsychotic medication. Findings: Record review from 6/19-22/17 revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admitting physician's orders [REDACTED].>Review of the medication order on 6/21/17 at 11:22 am, revealed [MEDICATION NAME] was started on 5/22/17, at another facility. Review of the pharmacist's admission review note dated 6/10/17, revealed .an AIMS assessment is to be completed on all patient's taking an antipsychotic upon admission and then every 6 months thereafter .Please complete an AIMS assessment. Review of the Nursing Notes dated 6/19/17 at 3:31 am, revealed an AIMS assessment was completed on 6/18/17, 11 days after admission. During an interview on 6/20/17 at 10:07 am, Nursing Supervisor (NS) #1 stated the AIMS assessment should be done within 1 week of admittance. The NS stated it is a little late. During a follow up interview on 6/21/17 at 11:25 am, NS #1 confirmed the Resident did not have an AIMS test done prior to admittance at the facility. During an interview on 6/21/17 at 3:15 pm, when asked when Residents AIMS testing should be done, the Pharmacist stated the AIMS test should be done within 3 days of admission. Review of the facility's policy [MEDICAL CONDITION] Medications dated 12/1/16, revealed .Licensed Nursing Staff .Complete the [MEDICAL CONDITION] Assessment and AIMS scale upon admission of a resident/patient with orders for [MEDICAL CONDITION] therapy . Review on 6/28/17 of the website http://www.rxlist.com/[MEDICATION NAME]-drug.htm#wa… | 2020-09-01 |
| 92 | 92 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 332 | D | 0 | 1 | NLCD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review the facility failed to ensure their medication (med) error rate was below 5%. Specifically, the facility failed to ensure 1 resident (#1), out of 7 residents observed during med pass observations, had received physician ordered medications at the correct scheduled times. In addition, the facility failed to ensure the medication error had been reported. The failure to follow the safe medication administration practices placed the resident at risk for not receiving necessary medications and placed all residents at risk for medication errors from a systemic failure to identify a root cause analysis of medication errors. Findings: Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility 4/26/17 with [DIAGNOSES REDACTED]. The Resident was at the facility to receive rehabilitation for an anticipated discharge home. Observation during a med pass on 6/20/17 at 1:50 pm revealed Licensed Nurse (LN) #4 prepared to administer medications to Resident #1. The LN removed 1 [MEDICATION NAME] 75 mg (a blood thinner) and 1 [MEDICATION NAME] 40 mg (an antidepressant) from the medication cart and administered them to the Resident. Review of the electronic Medication Administration Record [REDACTED]. Continuous observation on 6/21/17 from 7:20 am until 1:50 pm revealed the Resident was awake, ate breakfast, went to occupational therapy (OT) and physical therapy (PT) in the rehab department located in the building down the hallway, and returned to the unit and ate lunch. The Resident was not offered any scheduled morning medications during that time frame. During an interview on 6/20/17 at 1:50 pm, LN #4 stated Resident #1 had not received any of his/her am medications because the Resident had been in rehab all morning. Further review of the EMAR on 6/20/17 at 3:00 pm revealed the [MEDICATION NAME] and [MEDICATION NAME] had not been signed off. In addition, the medications Polyet… | 2020-09-01 |
| 93 | 93 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2017-06-22 | 466 | C | 0 | 1 | NLCD11 | Based on observation and interview, the facility failed to ensure a written protocol was in place for: 1) loss of water, potable and non-potable, 2) a method for distributing water, and 3) a method for estimating the volume of water required. The failure to ensure a written protocol was in place had the potential to affect all residents (based on a census of 39) in an event of loss water. Findings: Observation during a facility tour on 6/22/17 at 9:45 am, revealed 129 5-gallon containers in a storage unit. Further observation revealed 127 gallons of drinking water was also stored for emergency use. During an interview on 6/22/17 at 10:00 am the Director of Support Services (DSS) stated the facility did not have a written procedure in place for emergency water loss. The DSS further stated the water in the 5 gallon containers were to be changed every 2-3 years. During an interview on 6/22/17 at 11:00 am, Maintenance Staff (MS) #1 confirmed the facility did not have a written procedure related to emergency water loss. MS #1 further stated the 5 gallon water containers were to be refilled every 2 years. During an interview on 6/22/17 at 1:30 pm, the Infection Preventionist (IP) stated she understood that water never expired and therefore the 5 gallon water jugs were adequate. Additionally, the IP stated the facility used FEMA (Federal Emergency Management Agency) guidelines for the amount of water needed for an emergency. The IP stated the formula was 1 gallon/day per person times 3 days. Review on 6/22/17 at 1:50 pm of the FEMA pamphlet entitled Food and Water in an Emergency provided by the facility revealed Emergency Water Supplies .Store at least one gallon per person, per day. Consider storing at least a two-week supply of water for each member of your family. If you are unable to store this quantity, store as much as you can. | 2020-09-01 |
| 94 | 94 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 565 | E | 0 | 1 | FK4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to actively encourage and notify the residents (census of 47) participation in Resident Council meetings. This failed practice denied the residents' right to participate in resident group meetings and advocate for themselves. Findings: During an interview on 7/11/18 at 10:00 am, at an arranged meeting with residents, the residents present at the meeting (Resident #'s 15, 17, 30, 31 and 195) stated that they were not aware that the facility had a Resident Council and had not been invited to any Resident Council meetings. Record review on 7/9-13/18 revealed: Resident #15 was admitted to the facility on [DATE] Resident #17 was admitted to the facility on [DATE] Resident #30 was admitted to the facility on [DATE] Resident #31 was admitted to the facility on [DATE] Resident #195 was admitted to the facility on [DATE] During an interview on 7/13/18 at 1:40 pm, with the Director of Nursing and Quality Director, when it was brought to their attention that the residents were not aware of a Resident Council, they stated it could be fixed easily. Review of the facility's policy titled Resident Council, dated 7/1/17, revealed . (PTCC) recognize the residents' right to organize and participate in resident or family groups in the facility. Further review of the policy revealed .4. Each resident is a voting member of their facility's council and is encouraged to attend and participate in Council meetings. | 2020-09-01 |
| 95 | 95 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 656 | E | 0 | 1 | FK4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop/implement care plans to: 1) Address certain medical, mental and/or psychosocial needs and 2) Implement written care plan approaches for 4 out of 17 sampled residents (#s 24, 39, 194 and 195). This failed practice had the potential to effect all residents (based on a census of 47) of the facility by providing necessary services to maintain the residents highest practicable level of well being. Findings: Resident #24 Pacemaker Record review from 7/9-13/18 revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24's care plan, last updated 6/6/18, revealed no documentation of the presence of a cardiac pacemaker. In addition, there was no documentation any type of pacemaker device monitoring. Review of Resident #24's Resident Daily Care Plan (RDCP), dated 6/28/18, revealed no mention of a cardiac pacemaker. Random observations of the Residents room from 7/9-13/18 revealed no telephonic equipment for cardiac pacemaker monitoring for the Resident. Resident #39 Anti-coagulant Therapy Record Review from 7/9-13/18 revealed Resident #39 was admitted with [DIAGNOSES REDACTED]. Review of the Resident's Admission History & Physical dated5/25/18 revealed he/she was on [MEDICATION NAME] (a blood thinner that interferes with Vitamin K- clotting factors in the blood. [MEDICATION NAME] is a drug that may cause major or fatal bleeding, requires frequent blood monitoring, careful dosing adjustment, and diet monitoring. Other medications and over the counter supplements can affect this medication that may result in further thinning of the blood. It is important to avoid activities that could cause injury or bleeding as this has the potential to be fatal.) Record review of Resident #39's care plan, last updated 6/13/18, revealed no need/approach, preference, or goals to for issues related to anticoagulant therapy. Record review of the Resident D… | 2020-09-01 |
| 96 | 96 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 679 | E | 0 | 1 | FK4811 | Based on observation, interview and record review the facility failed to ensure support of resident participation in activity programs that included a variety of facility-sponsored group and individual activities based on individual assessment, care plan, and preference for 2 residents (#s 194 and 195), of 17 sampled residents reviewed. This failure practice placed residents at risk for boredom, loneliness, and decreased quality of life. Findings: Observation on 7/9/18 at 10:00 am, revealed one resident participating in the scheduled activity, Wheel Chair Exercise, alone. Observation on 7/9/18 at 11:39 am, revealed two residents in the common area. One Resident (#4) was observed to tell the other resident that it was time for Bible Study, the scheduled activity. Announcement of the activity overhead or staff efforts to ensure resident participation were not observed. Observation on 7/10/18 at 9:25 am, revealed the Activities Assistant (AA) coming in to the common area and starting the scheduled wheel chair exercise video. The AA did not leave the area to encourage or invite residents to the activity. A Resident arrived in the common area shortly after and the AA set up cards to play 1:1 (one to one). Observation on 7/10/18 at 10:00 am, revealed only one un-sampled Resident participating in the scheduled bible study group with the Pastor. No announcement of the activity or staff effort to invite residents to participate was observed. After 15 minutes, the Resident was taken out of the group to go to physical therapy. During an interview on 7/10/18 at 10:25 am, Certified Nursing Assistant (CNA) #1 stated it was the person performing the activity who is responsible for going around and asking the residents if they want to participate. During an interview on 7/10/18 at 11:00 am, the Pastor for bible study stated there was consistently poor participation in his groups because of all the therapy that is taking place at that time. He stated he was mainly responsible for inviting Residents to his group and rarely sees st… | 2020-09-01 |
| 97 | 97 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 684 | E | 0 | 1 | FK4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 3 residents (#'s 16, 24 and 39), out of 3 residents reviewed with cardiac devices (devices implanted under the skin with wires attached to the heart to ensure a regular heartbeat) had the required monitoring of the device. This failed practice placed the residents at risk for undiagnosed heart rhythm irregularities, missed device changes or alerts, and decreased heart health. Findings: Resident #16 Record review from 7/9-13/18 revealed Resident #16 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #16's care plan, last updated 5/9/17, revealed no documentation of the presence of a pacemaker or any type of cardiac device monitoring. Review of Resident #16's Resident Daily Care Plan (RDCP), dated 5/15/18, revealed no documentation of a cardiac pacemaker. Record review of Providence Alaska Medical Center's Admission History and Physical, dated 4/11/18, revealed Review of old records indicate that patient is had a pacemaker placed for heart block following a [MEDICAL CONDITION] infarction. This was in 2008. Record review of PTCC (Providence Transitional Care Center) ADMISSION TRANSFER REPORT, dated 4/26/18, revealed PMH (past medical history): .PACEMAKER. Review of PHYSICIAN ORDER REVIEW, dated 5/3/18, 5/27/18 and 6/28/18 revealed INFO: Patient has PACEMAKER . Observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker monitoring, present for the Resident. An interview on 7/12/18 at 3:10 pm, with Alaska Heart & Vascular Institute Electrophysiology Clinic Manager (AH&VI EP Manager), revealed Resident #16 had his/her last pacemaker transmittal on 1/24/18. The Resident was scheduled for transmittals 5/1/18, 5/15/18, 6/5/18, and 6/19/18. The Manager stated as these transmittals were all missed, no other transmittals had been scheduled for this Resident. Resident #24 Record review from 7/9-13/18… | 2020-09-01 |
| 98 | 98 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 689 | D | 1 | 1 | FK4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure the safety of 1 Resident (#2) who resided in the facility. Specifically, the facility failed to ensure the Roam Alert Resident Safety (RARS- a door alarm system intended to alert staff of elopement/wandering from the building or a designated area of the building) was checked regularly for proper functioning that resulted in resident #2 leaving the facility unsupervised. This failed practice placed the resident at risk being without medical supervision and unsafe environment conditions. Findings: Based on a closed record review of an elopement the facility is cited for past non-compliance for elopement of resident #2. Upon the Resident's return to the facility, the facility found no system in place for checking the monitoring device and had developed a protocol for monitoring and recording this information on the Residents Treatment Administration Record. Record review of a closed record from 7/10-13/18 revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's care plan dated 4/2/18, revealed NEED/PREFERENCE .I LIKE: to wander about and sometimes go outside .I SHOW THIS BY: going outside at times, without telling staff .APPROACH .I need my nurses to---chart on my behavior in regards to the wander guard that I wear .GOAL .MY GOAL IS TO: stay safe while I'm moving about . Record review revealed no documentation of the Resident using the RARS and no documentation of staff checking the system. Further review of the medical record revealed no documentation of resident eloping in the medical record. Review of the facility report incident dated 5/24/18, revealed the facility reported the elopement to the state agency (Health Facilities Licensing & Certification). During an interview with Nursing Supervisor (NS) #1 on 7/13/18 at 12:05 pm, when asked for documentation in the medial record of Resident #2's elopement the NS stated he/… | 2020-09-01 |
| 99 | 99 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 726 | E | 0 | 1 | FK4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure staff had appropriate competencies and skills necessary to care for include the clinical needs of 2 residents #s (16 and 24) with pacemakers and 1 resident (#39) bi-ventricular implantable cardiac defibrillator (BI-V ICD- a special type of pacemaker with a defibrillator used to resynchronize the heart muscle in heart failure patients) in the facility, out of 3 sampled residents with implanted devices. This failed practice placed the residents at risk for undiagnosed heart rhythm irregularities, missed necessary cardiac monitoring, equipment, care and decreased heart health. Findings: Resident #16 Record review from 7/9-13/18 revealed Resident #16 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #16's care plan, last updated 5/9/17, revealed no documentation of the presence of a pacemaker or any type of cardiac device monitoring. Review of Resident #16's Resident Daily Care Plan (RDCP), dated 5/15/18, revealed no documentation of a cardiac pacemaker. Random observations from 7/9-13/18 revealed no telephonic equipment for cardiac pacemaker monitoring for the Resident. Resident #24 Record review from 7/9-13/18 revealed Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #24's care plan, last updated 6/6/18, revealed no documentation regarding any type of pacemaker monitoring. During an interview on 7/12/18 at 10:10 am, with Resident #24's son and daughter, Resident's #24's son stated that he had no interaction with the staff regarding Resident #24's pacemaker. Random observations of the resident's room from 7/9-13/18 revealed no telephonic equipment, used for cardiac pacemaker monitoring, present for the Resident. Resident #39 Record review from 7/9-13/18 revealed Resident #39 was admitted to the facility with a [DIAGNOSES REDACTED]. During an interview on 7/9/18 at 9:17 am, Resident #39 stated that they had a BI-V I… | 2020-09-01 |
| 100 | 100 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 756 | D | 0 | 1 | FK4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure accurate drug regimen review for 1 resident (#7) out of 17 sampled residents, reflected a medication contraindication as referred by the Beers list ( Criteria for Potentially Inappropriate Medication use in Older Adults) was acted on in a timely manner. This failed practice placed the resident at increased risk for confusion, [MEDICAL CONDITION], falls and fractures. Findings: Record review on 7/9-13/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. (A benzodiazepine that is primarily used to treat anxiety). Review of Pharmacy Recommendations for Resident #7 revealed a monthly review, dated 6/27/18 at 12:35pm, revealed: .PRN [MEDICATION NAME] ([MEDICATION NAME]) was ordered last night for use PRN agitation or [MEDICAL CONDITION]. Not the best choice, but better than a PRN antipsychotic. Will increase fall risk at night and will need close monitoring. Nursing staff to attempt 1:1 (one to one) care when staffing allows. Further review of Resident #7's chart revealed no drug regimen review sheet to alert the physician of these recommendations for increased observation. Record review of Resident #7's active care plan last reviewed 4/4/18 revealed: I need to have someone help me .am unaware of safety risks .have the potential to fall down and hurt myself. I am at risk for injuring myself . During an interview on 7/11/18 at 12:50 pm, the Pharmacist stated the 6/27/18 monthly review did not address the [MEDICATION NAME] order was contraindicated for the elderly population on the Beers list for treatment of [REDACTED]. The Pharmacist further stated the Pharmacist reviewing the record should have reported the concern and documented it on the review. Review of the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication use in Older Adults, dated 2012, reads, Avoid Benzodiazepines (any … | 2020-09-01 |
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CREATE TABLE [cms_AK] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );