cms_AL
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3122 | 3122 | ANNISTON HEALTH AND REHAB SERVICES | 15375 | P.O. BOX 1825 | ANNISTON | AL | 36207 | 2016-04-01 | 226 | J | 0 | 1 | KFHX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Based on interviews, record reviews the facility failed to follow their policy and procedure on Abuse and Neglect by failing to implement the Protection and Reporting elements of the policy when RI (Resident Identifier) #1 made an allegation of sexual abuse against EI (Employee Identifier) #3. On 3/6/2016, RI #1 called the Administrator at home and made an allegation of sexual abuse against EI #3. According to RI #1, EI #3 entered the resident's room on 3/3/2016 and began massaging the resident's chest. Then EI #1 placed his hand in RI #1's pants touching the genital area. The Administrator called the facility and informed EI #3 of RI #1's allegation. After being informed of the allegation by the Administrator, EI #3 went RI #1's room. According to RI #1, EI #3 cursed at the resident. EI #3 worked his shift and reported to work the next day on his scheduled shift (7 AM to 3 PM) during the investigation of the incident. This deficient practice placed RI #1, one of three sampled residents reviewed for abuse, in immediate jeopardy, as it was likely to cause serious injury, harm, or death and had the potential to affect all 39 resident's in the facility. On 4/1/2016 at 7:50 PM, the facility's Administrator, EI #1, Director of Nursing, EI #2, Social Service Director, EI #8, Assistant Administrator, EI #10 and the LPN (Licensed Practical Nurse) Supervisor, EI #4 were notified of the findings of substandard quality of care at the immediate jeopardy level of L in the area of Resident Behavior & Facility Practices, F 226. 2) The facility further failed to ensure the Abuse Registry was checked prior to employment for three of six employee records reviewed. Findings include: The state agency received a complaint on 3/24/2016. The complainant alleged RI #1 called the facility's Administrator on 3/6/2016 and reported that on 3/3/2016, the ADON (Assistant Director of Nursing), EI #3, went into RI #1's room about 10:00 AM and sat on the bed next to the r… | 2019-07-01 |
| 2860 | 2860 | NORTHWAY HEALTH AND REHABILITATION, LLC | 15047 | 1424 NORTH 25TH STREET | BIRMINGHAM | AL | 35234 | 2016-09-22 | 325 | D | 1 | 0 | EIE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Base on observation, interviews and record review, the facility failed to provide Resident Identifier (RI) #3, a resident identified by the facility as having weight loss, with a house shake on the breakfast meal tray on 9/21/2016. The house shake was added to provide additional calories and protein for the resident. This affected one of three sampled residents received for weight loss. Findings include: The facility's policy titled Nutritional Supplements (NP.I-74) effective 10/1/2010, documented PURPOSE: Residents may, from time to time, receive supplements to their regular meals, when a particular modified diet requires such supplementation to meet the nutritional needs of the resident, or the resident's intake is such that additional nutrition is needed . PR[NAME]ESS: . b) The dietary department should send nutritional supplements, . for each resident . RI #3 was admitted to the facility on [DATE]. RI #3's progress note dated 6/2/2016 11:55 AM, written by Employee Identifier (EI) #11, the Registered Dietician (RD) documented . Due to downward wt (weight) trend, recommend to try adding a house supplement once daily to provide add'l (additional) kcals (kilocalorie) and protein . RI #3's progress note dated 6/6/2016 3:00 PM,written by the Certified Dietary Manager documented House shake added to b'fast (breakfast) to provide additional kcals an (and) protein, will follow. RI #3's WEEKLY WEIGHT REVIEW 11/14 dated 6/17/2016, indicated the resident had a five pound weight loss in the last seven days. The interventions added were HOUSE SHAKE ADDED TO BREAKFAST . * RI #3's care plan titled Actual weight loss . with a problem onset date of 6/17/2016 and last reviewed 8/25/2016, had a documented approach of . Provide snacks or supplements . RI #3's Quarterly Minimum Data Set with an assessment reference date of 8/31/2016 revealed RI #3 required extensive assistance with eating. During this assessment period, RI #3 was identified as having weight … | 2019-09-01 |
| 1779 | 1779 | MONROE MANOR HEALTH & REHABILITATION CENTER | 15398 | 236 WEST CLAIBORNE STREET | MONROEVILLE | AL | 36460 | 2017-10-05 | 441 | D | 1 | 1 | D8MR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based an observation, a review of the manufacturer's guidelines and interviews, the facility failed to ensure the injection port of a [MEDICATION NAME] was cleaned prior to attaching the [MEDICATION NAME] needle. This affected RI (Resident Identifier) #11, one of four residents observed receiving an injection from the [MEDICATION NAME] system. Findings Include: A review of the Manufacturer's Guidelines: .HUMOLOG insulin [MEDICATION NAME] injection 100 units/ML(Milliliter) Step 1: Preparing your [MEDICATION NAME](R) [MEDICATION NAME](R) Wash your hands. Check the label to make sure that you are using the right type of insulin. This is especially important if you take more than 1 type of insulin Pull off the pen cap. Wipe the rubber [MEDICATION NAME] with an alcohol swab . A review of the medical record revealed RI #11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 8/01/2017, revealed RI #11 had a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15, indicating RI #11 was cognitively intact for daily decision making. RI #11 was assessed as needing extensive assistance from staff for ADLs (Activities of Daily Living) except for eating, which RI #11 required setup assistance only. An observation was made at 5:02 p.m. on 10/3/2017. EI (Employee Identifier)#7, LPN (Licensed Practical Nurse) obtained a Humalog [MEDICATION NAME] from the medication cart. EI #7 obtained a [MEDICATION NAME] needle and removed the cap of the [MEDICATION NAME] and attached the [MEDICATION NAME] needle (No cleaning of the injection port was performed prior to attachment of the [MEDICATION NAME] needle). An interview was conducted at 1:05 p.m. on 10/5/2017 with EI #7. EI #7 was asked if the injection port needed to be cleaned prior to attaching the [MEDICATION NAME] needle. EI #7 replied yes. EI #7 was asked why the injection port needed… | 2020-09-01 |
| 1427 | 1427 | BIRMINGHAM NURSING AND REHABILITATION CTR LLC | 15217 | 1000 DUGAN AVENUE | BIRMINGHAM | AL | 35214 | 2019-06-22 | 656 | D | 1 | 0 | 9BCV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based medical record review and interviews, the facility failed to ensure Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA), followed Resident Identifier (RI) #2's care plan and Daily Care Guide on how to transfer the resident. On 5/11/2019, EI #3, a CNA, used a total lift, without the assistance of another staff member to transfer RI #2 from the resident's bed to the bath boat. This deficient practice affected RI #2, one of six sampled residents reviewed for accidents. Findings include: RI #2 was readmitted to the facility on [DATE] with a medical history to include [DIAGNOSES REDACTED]. RI #2's Quarterly Minimum Data Set with an assessment reference date of 4/15/2019, indicated RI #2 was severely impaired cognitive skills for daily decision making, with short and long term memory problems. RI #2 was assessed as being totally dependent on staff for transfers, with two person physical assistance. RI #2's care plan titled (RI #2) requires total assist with ADLs (Activities of Daily Living) with a problem onset date of 4/25/2011 and last reviewed 4/15/2019, had an approach of . Transfer with full body lift and staff of two . RI #2's undated Daily Care Guide (Pocket Care Guide) listed the following intervention: . Transfer using Total lift with 2 person assist using medium sling . On 5/29/2019 at 3:42 AM, an interview was conducted with EI #3, a CN[NAME] EI #3 was asked what RI #2's care plan stated regarding transferring RI #2 with the total lift. EI #3 stated to use a two person assist. EI #3 was asked if she used a two person assist when she transferred RI #2 to the bath boat on 5/11/2019. EI # 3 stated no. EI #3 stated she transferred RI #2 by herself using the total lift. EI #3 was asked why she should use a two person assist if the care plan states to use a two person assist. EI #3 stated the resident could have fallen or had an accident. On 5/29/2019 at 9:08 AM, an interview was conducted with EI #5, the Care Plan Coordin… | 2020-09-01 |
| 2874 | 2874 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 514 | D | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based observation, record review and interview the facility failed to maintain a complete clinical record on RI (Resident Identifier)#1 to reflect the incident on 09/13/2016. The facility further failed to document the behaviors on RI #4 that necessitated the use of disposable dinnerware. This affected two of four sampled residents. Findings Include: A review of the Alabama Board of Nursing Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.06 Documentation Standards . (c) Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, responses, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient. A signature of the writer, whether electronic or written, is required in order for the documentation to be considered complete. A review of a facility document titled Behavior Assessment and Monitoring with a revised date of (MONTH) 2007 revealed: .Policy Interpretation and Implementation . Monitoring . 1. If the resident is being treated for [REDACTED]. 2. The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: a. Number and frequency of episodes; b. Preceding or precipitating factors; c. Interventions attempted . d. Outcomes associated with interventions. 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, RI #1 was admitted to Hospice Service on 8/13/16. The admission Minimal Data Set (MDS) with the assessment reference date of 8/19/16 revealed RI #1 scored a 14 out a possible score of 15, which indicates he/she was cognitively alert. RI #1 was dependent for transfers and did not ambulate since she had lower extremity deficits. On 9/20/2016 the Department of Public Health … | 2019-09-01 |
| 188 | 188 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2019-12-05 | 625 | D | 1 | 1 | PZGJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a complaint received by the Alabama State Survey Agency, the facility's Bed Hold Policy, Resident Identifier (RI) #264's medical record and interviews, the facility failed to provide RI #264 written notice which specified the duration of the bed hold, reserve bed payment, the facility's policy regarding bed hold and the conditions upon which RI #264 would be able to return to the facility, when RI #264 was transferred/discharged from the facility to a hospital's emergency roiagnom on [DATE]. This deficient practice affected RI #264, one of one sampled resident reviewed for a facility-initiated discharge. Findings include: On 9/17/2019, the State Agency received a complaint which alleged the facility discharged RI #264 to a hospital's emergency roiagnom on [DATE] and would not accept the resident back into the facility. The facility's policy titled Bed Hold Policy dated 11/1/2016, documented POLICY STATEMENT Diversicare will, in accordance, with Federal and State regulations, hold a Resident's bed during a temporary hospitalization or therapeutic leave. PR[NAME]EDURE 1. Before the Center transfers a Resident to a hospital or the Resident goes on therapeutic leave, the Center shall provide Resident or his or her Resident Representative this Bed Hold Policy . RI #264 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED].#264 has a medical history to include [DIAGNOSES REDACTED]. RI #264's ADMISSION RECORD dated 4/10/2019 indicated the resident was his/her own responsible party. RI #264 Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/17/2019 indicated the resident was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status of three. RI #264's MDS with an assessment reference date of 8/12/2019 indicated the resident had a planned discharged to an acute hospital with return not anticipated on 8/12/2019. RI #264's Progress Notes written by Employ… | 2020-09-01 |
| 189 | 189 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2019-12-05 | 626 | D | 1 | 1 | PZGJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a complaint received by the Alabama State Survey Agency, the facility's policies titled Transfer & Discharge and Bed Hold Policy, Resident Identifier (RI) #264's medical record and interviews, the facility failed to allow RI #264 to return to the facility following a transfer/discharge to a local hospital. This deficient practice affected RI # 264, one of one sampled resident reviewed for a facility-initiated discharge. Findings include: On 9/17/2019, the State Agency received a complaint which alleged the facility discharged RI #264 to a hospital's emergency roiagnom on [DATE] and would not accept the resident back into the facility. The facility's policy titled Bed Hold Policy dated 11/1/2016, documented POLICY STATEMENT Diversicare will, in accordance, with Federal and State regulations, hold a Resident's bed during a temporary hospitalization or therapeutic leave. PR[NAME]EDURE . 5. If the Center determines that the Resident cannot return to the facility after a hospital or therapeutic leave, it shall comply with its Transfer and Discharge Policy. The facility's policy titled Transfer & discharge date d 11/1/2016, documented POLICY STATEMENT Diversicare shall permit each Resident to remain at the Center, and not transfer or discharge the Resident from the Center except in accordance with Federal and State laws, and as described in this policy . RI #264 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED].#264 has a medical history to include [DIAGNOSES REDACTED]. RI #264's ADMISSION RECORD dated 4/10/2019 indicated the resident was his/her own responsible party. RI #264 Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/17/2019 indicated the resident was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status of three. RI #264's MDS with an assessment reference date of 8/12/2019 indicated the resident had a planned discharged to an acute… | 2020-09-01 |
| 187 | 187 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2019-12-05 | 623 | D | 1 | 1 | PZGJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a complaint received by the Alabama State Survey Agency, the facility's policy titled Transfer & Discharge, Resident Identifier (RI) #264's medical record and interviews, the facility failed to issue RI #264's a 30-day notice of discharge when the resident was discharged from the facility on 8/12/2019. This deficient practice affected RI # 264, one of one sampled resident reviewed for a facility-initiated discharge. Findings include: On 9/17/2019, the State Agency received a complaint which alleged the facility discharged RI #264 to a hospital's emergency roiagnom on [DATE] and would not accept the resident back into the facility. The facility's policy titled Transfer & discharge date d 11/1/2016, documented POLICY STATEMENT Diversicare shall permit each Resident to remain at the Center, and not transfer or discharge the Resident from the Center except in accordance with Federal and State laws, and as described in this policy. PR[NAME]EDURE . Notice Requirements 5. Before Diversicare transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand; and will also notify the State Long-Term Care Ombudsman. 6. The Notice of Transfer shall include the information required under the law, including the Resident's appeals rights, and shall be provided at least 30 days before the proposed date of transfer or discharge unless sooner notice is permitted . RI #264 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED].#264 has a medical history to include [DIAGNOSES REDACTED]. RI #264's ADMISSION RECORD dated 4/10/2019 indicated the resident was his/her own responsible party. RI #264 Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/17/2019 indicated the resident was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status of three. RI … | 2020-09-01 |
| 1306 | 1306 | DECATUR HEALTH & REHAB CENTER | 15206 | 2326 MORGAN AVENUE SOUTHWEST | DECATUR | AL | 35603 | 2018-01-25 | 695 | D | 1 | 0 | JMTW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a complaint submitted to the Alabama State Survey Agency, interviews conducted, review of Resident Identifier (RI) #1's medical record and an Emergency Medical Services (EMS) report, the facility failed to ensure oxygen was available to the resident when admitted to the facility on [DATE]. This deficient practice affected RI #1, one of three reviewed for oxygen care. Finding include: On 1/11/2018, the Alabama State Survey Agency received a complaint which alleged the facility did not have oxygen available when RI #1 was admitted on [DATE]. RI #1 was admitted to the facility on [DATE], from a local hospital, with an admitting [DIAGNOSES REDACTED].#1 has a medical history to include: [MEDICAL CONDITION] and Acute and Chronic [MEDICAL CONDITION]. During a telephone interview on 1/23/2018 at 1:45 PM, RI #1's daughter stated RI #1 was admitted to the nursing facility on 1/10/2018 around 10:00 PM from a local hospital. RI #1's daughter stated the resident required oxygen. When asked how long RI #1 was without oxygen, RI #1's daughter stated 30 minutes. She further explained the facility did not have any oxygen in the room and they were aware RI #1 was coming. The local hospital's physician's orders [REDACTED].#1 will be admitted to Decatur Health & Rehab, with respiratory care orders for four liters of oxygen per nasal cannula. RI #1's Departmental Notes dated 1/10/2018 10:09 PM written by Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) documented pt (patient) noted to arrive at facility at 10PM via EMS (Emergency Medical Services) with family at (his/her) side, noted pt is currently on 4 LPM (liters per minute) O2 (oxygen) via NC (nasal cannula) . 93% on 4LPM O2 via NC. In an interview on 1/24/2018 at 4:12 PM, EI #2, a LPN stated she had received report from the local hospital around 4:00 PM (on 1/10/2018) that RI #1 was on four liters of oxygen via nasal cannula. According to EI #2, she was informed by the hospital that R… | 2020-09-01 |
| 1702 | 1702 | CANTERBURY HEALTH CARE FACILITY | 15382 | 1720 KNOWLES ROAD | PHENIX CITY | AL | 36869 | 2017-08-15 | 282 | J | 1 | 0 | W4LZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of Resident Identifier (RI) #1's medial record, interview with the resident and staff interviews, the facility failed to implement the care plan of RI #1, a resident admitted to the facility with a Stage IV pressure ulcer to the sacral region. RI #1's care plan titled I am at risk for impaired skin integrity . had interventions to provide wound care as ordered, offer supplemental nutrition and weekly evaluation of wound healing. These interventions were not implemented as care planned. RI #1 was admitted to the facility on [DATE] and discharged home on[DATE]. During RI #1's entire stay in the nursing facility, the licensed nursing staff failed to conduct weekly wound/skin assessments of RI #'1 Stage IV pressure ulcer to the sacral region. RI #1 was ordered to have the wound vac changed on Mondays and Thursdays. A review of RI #1's electronic Treatment Administration Record (eTAR) and staff interviews revealed, RI #1's wound vac was not consistently changed as ordered and care planned. Also, it was recommended and ordered by the physician on 6/19/2017 for RI #1 to have Juven and a protein supplement to aid in wound healing. This intervention was not implemented and RI #1 never received the recommended and ordered Juven and protein supplement. These deficient practices placed RI #1, one of nine sampled residents reviewed for pressure ulcer care, in immediate jeopardy as these failures could have caused serious harm, injury or death. On 8/17/2017 at 4:25 p.m., EI #1, the Administrator was informed the scope and severity of F 282, Comprehensive Care Plan was increased to an immediate jeopardy level [NAME] Findings include: RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #1's care plan titled I am at risk for impaired skin integrity and I have a Stage 4 pressure ulcer to sacrum . with a problem onset date of 6/5/2017 had the following approaches . * I need a wound care as ordered by physician . * Of… | 2020-09-01 |
| 1703 | 1703 | CANTERBURY HEALTH CARE FACILITY | 15382 | 1720 KNOWLES ROAD | PHENIX CITY | AL | 36869 | 2017-08-15 | 314 | J | 1 | 0 | W4LZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of Resident Identifier (RI) #1's medical record, review of www.webmd.com, the facility's policies titled Care System Guideline Skin Care, Medication Policies Prescriber Medication Orders and Supplements and resident and staff interviews, the facility failed to: 1) complete an initial wound assessment of RI #1's infected Stage IV sacral pressure ulcer. RI #1 was admitted to the facility on [DATE] with an infected Stage IV pressure ulcer to the sacral region. The admission nurse failed to conduct an initial wound assessment of the resident's pressure ulcer. The only wound/skin assessment found within RI #1's medical record was a Skin Inspection Report dated 6/6/2017 that documented Skin Not Intact - Existing; 2) transcribe the admission wound care orders to change the wound vac on Mondays and Thursdays. RI #1's wound care orders were not transcribed until 6/8/2017 with a start date of 6/12/2017. When questioned why the delay in wound care orders, the admission nurse, Employee Identifier (EI) #9 stated she forgot; 3) consistently change the wound vac as ordered. A review of the electronic Treatment Administration Record (eTAR) and staff interviews revealed, the resident's wound vac was not changed as ordered by the physician; 4) conduct subsequent wound/skin assessments of RI #1's infected Stage IV sacral pressure ulcer. During the course of RI #1's stay at the nursing facility, from 6/5/2017 until 7/6/2017, there was no evidence the licensed nursing staff conducted weekly wound/skin assessments as listed in the facility's policy and RI #1's care plan. The weekly wound assessments, that was the responsibility of the Treatment Nurse, were not done. The facility's Treatment Nurse left the faciity on [DATE] and the administrative staff had no system in place to ensure wound/skin assessments were completed weekly; and 5) follow the Registered Dietician's (RD) recommendation and physician's orders [REDACTED].#1, to aid in the heal… | 2020-09-01 |
| 2356 | 2356 | ATMORE NURSING CENTER | 15129 | 715 EAST LAUREL STREET | ATMORE | AL | 36502 | 2017-04-01 | 323 | J | 1 | 0 | TB2211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of Resident Identifier (RI) #1's medical record, the facility's policy and procedure for elopement and missing residents, the facility's Resident Incident Report, the Almanac for ATMORE, AL (MONTH) 27, (YEAR), www.mapquest.com, an email from the local hospital's security guard, the ALABAMA UNIFORM INCIDENT/OFFENSE REPORT nursing home and hospital staff interviews, and the facility's corrective action plan, the facility failed to ensure RI #1, a cognitively impaired resident who wore a secure care alarm anklet, did not exit the facility without staff knowledge on 3/27/17. On 3/27/17 around 7:30 PM, the facility's secure care alarm sounded. Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) responded, along with EI #5, a Certified Nursing Assistant (CNA). EI #5 held the door while EI #3 looked in the facility's parking lot. After nothing was seen outside, EI #3 came back inside, reset the alarm and continued with medication pass. The staff failed to implement their policy to ensure all residents with a Secure Care bracelet was accounted for. Then around 8:15 PM, after the resident had to be identified a police officer, a local hospital staff member called the nursing home to inform them that RI #1 had been found wandering around the parking lot of the local hospital, 0.10 miles away from the facility. According to the hospital's security guard, the resident was found about five to six feet from a big ditch about to fall. The security guard stated that if the resident would have fell in the ditch, it would have been days before someone would have found him/her. The LPN, EI #3, sent EI #4, a CNA to the local hospital to get RI #1. RI #1 was returned to the facility without injury. This deficient practice placed RI #1, one of three sampled residents, in immediate jeopardy of serious injury, harm or death. On 4/1/17 at 6:10 PM, Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing were noti… | 2020-08-01 |
| 1432 | 1432 | BIRMINGHAM NURSING AND REHABILITATION CTR LLC | 15217 | 1000 DUGAN AVENUE | BIRMINGHAM | AL | 35214 | 2017-11-02 | 282 | G | 1 | 0 | 354211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of Resident Identifier (RI) #1's medical record, the facility's policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS and staff interviews, the facility failed to ensure Employee Identifier (EI) #1 and EI #6, both Certified Nursing Assistants (CNAs) followed RI #1' s care plan on how to transfer the resident. On 7/25/2017, EI #1, a CNA, used a sit to stand lift, without the assistance of another staff member to transfer RI #1. During the transfer, RI #1 became weak, let go of the lift and slid to the floor. RI #1 did not sustain any injuries; however, on 9/14/2017, EI #6, a CNA attempted to transfer RI #1 from the bed to the wheelchair. EI #6 did not follow the care plan when she failed to utilize the lift with the assistance of another staff during this transfer. RI #1's knees became weak and the resident was lowered to the floor. RI #1 complained of bilateral knee pain. An X-ray was done which revealed RI #1 sustained a left femur (bone of the thigh) fracture. This affected RI #1, one of three sampled residents reviewed for falls. Findings include: The facility's policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS documented POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Pocket Care Guide - part of the Comprehensive Care Plan and used as the tool to make staff aware of the resident's daily care needs .PR[NAME]EDURE: . 6. Staff approaches are to be developed . Assigned disciplines will be identified to carry out the intervention . On 10/27/2017, the Alabama State Survey Agency received a complaint which alleged in (MONTH) (YEAR), while being transferred from the Hoyer lift by the assistance of one CNA, RI #1 slipped from the Hoyer lift and was lowered the floor. An in-house X-ray was done which revealed RI #1 sustained a left femur fracture. RI #1 was readmitted to the fa… | 2020-09-01 |
| 766 | 766 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 272 | J | 1 | 0 | 5G6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of Resident Identifier (RI) #1's medical record, www.dictionary.com and staff interviews, the facility failed to ensure RI #1's ELOPEMENT RISK ASSESSMENT indicated whether the resident was at risk of elopement. Elopement is defined as an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment. Further, the facility failed to reassess RI #1 for elopement risk when the resident voiced repeated statements about his/her desire to leave the facility. With an incomplete assessment and no behavioral interventions to redirect the resident's behavior, during the early morning hours on 6/9/2017, RI #1 eloped from the facility, without staff knowledge. RI #1 was found by a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped, without staff knowledge, from[NAME]Health & Rehab Center. Refer to F 323. These deficient practices placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of immediate jeopardy level in the area of Resident Assessments, F 272. Findings include: According to www.dictionary.com, elopement is defined as . an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's ELOPEMENT RISK assessment dated [DATE], comp… | 2020-09-01 |
| 1706 | 1706 | CANTERBURY HEALTH CARE FACILITY | 15382 | 1720 KNOWLES ROAD | PHENIX CITY | AL | 36869 | 2017-08-15 | 502 | D | 1 | 0 | W4LZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of Resident Identifier (RI) #3's medical record and staff interview, the facility failed to ensure a Basic Metabolic Profile (BMP), a laboratory test, was obtained as ordered for RI #3. This affected one of nine residents whose labs were reviewed. Findings include: RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's (MONTH) (YEAR) Physician order [REDACTED]. A review of a facility document titled Clinical Laboratory Services documented . DATE DRAWN 2/27/2017 . TEST NAME . BASIC METABOLIC . On 08/12/2017 at 5:30 p.m., an interview was conducted with Employee Identifier (EI) #6, the Registered Nurse (RN) Unit Manager. EI #6 was asked what did the physician order [REDACTED]. EI #6 said to collect it every three months. EI #6 was asked when was the last BMP. EI #6 said 02/27/2017. EI #6 was asked why was that the last BMP drawn. EI #6 said because it didn't get drawn. EI #6 was asked who was responsible to ensure the lab orders were obtained. EI #6 stated, she was. EI #6 was asked why was it important to obtain the BMP. EI #6 said to monitor the electrolytes. This deficiency was cited as a result of the investigation of complaint/report number AL 237. | 2020-09-01 |
| 765 | 765 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 250 | J | 1 | 0 | 5G6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of the facility's Behavior Management policy, Resident Identifier (RI) #1's medical record and staff interviews, the facility failed to ensure RI #1, a cognitively impaired resident identified as at risk for elopement, who repeatedly voiced a desire to leave the facility, was placed on a behavior management plan to address repeated wandering/exit-seeking behavior. Beginning in (MONTH) (YEAR), RI #1, a resident diagnosed with [REDACTED]. In (MONTH) (YEAR), RI #1 called a taxi to take him/her away from the facility. Then two days before RI #1 eloped from the facility, on 6/7/2017, the resident was observed cursing stating he/she had to leave this place and looking out the door. During the early morning hours on 6/9/2017, RI #1 eloped from the facility, without staff knowledge and was found a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped from[NAME]Health & Rehab Center. Staff interview revealed, RI #1's elopement could have potentially been avoided had the facility placed the resident on a behavior management plan in (MONTH) (YEAR), when the RI #1 began to voice a desire to leave the facility. This deficient practice placed RI #1, one of four sampled residents in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON); and EI #18, the Regional Nurse Consultant, were notified of the findings of immediate jeopardy level in the area of Medically Related Social Services, F 250. Findings include: The facility's policy with a subject title … | 2020-09-01 |
| 506 | 506 | RIVER CITY CENTER | 15113 | 1350 FOURTEENTH AVENUE SOUTHEAST | DECATUR | AL | 35601 | 2017-08-04 | 514 | D | 1 | 0 | 9I2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a staff interview, review of Resident Identifier (RI) #2's medical record and the facility's policy titled Medication Administration: General, Employee Identifier (EI) #4, a Registered Nurse (RN) failed to document the administration of Tylenol, a pain medication, that was administered to RI #2 on 8/2/2017. This deficient practice affected RI #2, one of four sampled residents. Findings Include: The facility's policy titled Medication Administration: General with an effective date of 1/1/2014, revealed: . PURPOSE To provide a safe effective medication administration process . 8. Document: 8.1 Administration of medication on Medication Administration Record [REDACTED] RI #2 was admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. RI #2's Medication Administration Record [REDACTED]. An interview on 8/3/2017 at 6:45 p.m., was conducted with EI #4, a RN. EI #4 was asked if she administered Tylenol for pain to RI #2. EI #4 answered that she gave RI #2 one Tylenol 325 milligram tablet by mouth for pain on 8/2/2017. When asked if the administration of Tylenol was documented, EI #4 replied no, she did not. EI #4 was asked, what the potential harm for administering a medication and not documenting it. EI #4 stated, it could interact with another medication or it could be given again too soon. This deficiency was cited as a result of the investigation of complaint/report number AL 258. | 2020-09-01 |
| 1047 | 1047 | PARKWOOD HEALTH CARE FACILITY | 15179 | 3301 STADIUM DRIVE | PHENIX CITY | AL | 36867 | 2017-06-22 | 493 | E | 1 | 0 | B1DM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an accounting record review of expired residents' Trust Funds, an interview with Corporate staff and review of email communication from the Corporation to the facility, the Corporation failed to give the facility permission to release the funds in the expired residents Trust Fund accounts to the agency or sponsor within the required thirty day deadline. This affected a total of 4 of 8 expired residents whose Trust Funds were reviewed. Three expired residents had funds which should have been returned to the Social Security Administration (SSA), and one expired resident had funds which should have been returned to the sponsor. Findings Include: On [DATE] a review was conducted of the eight expired residents that had Trust Fund accounts managed by the facility. Findings revealed that out of the eight expired residents, four had excess funds left in their accounts after the thirty day mandated disbursement requirement. Resident Identifier (RI) #21, 22, and 23 had excess funds that had not been returned to the SSA within the thirty day deadline and RI #20 had funds that had not been returned to their sponsor within the thirty day deadline. An email from the Corporation's office to the facility, dated [DATE] at 9:53 a.m., revealed the following: . We ask the facilities not to disburse any funds due back to Social Security on a resident that has passed away until they receive a letter from the Social Security office requesting these funds be returned. They are required to contact their Social Security office prior to the 30 days after the resident's passing to inform them that we have funds to be refunded back to them and need a request to issue those funds back to them. We have had many issues in the past where we send the monies back to Social Security before the 30 days and before a letter requesting the funds back is received and the Social Security office end up also taking the funds back out of the Resident Trust checking account el… | 2020-09-01 |
| 2458 | 2458 | SUMMERFORD NURSING HOME INC | 15075 | 4087 HIGHWAY 31 SOUTHWEST | FALKVILLE | AL | 35622 | 2017-02-23 | 225 | L | 1 | 0 | U6DO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an anonymous complaint received by the State Agency, the facility's abuse policy and Employee Identifier (EI) #1's Application for Employment and Background Verification Report and staff interviews, the facility allowed EI #1, a Registered Sex Offender, to be hired by the facility on 4/26/2016. EI #1's criminal background check dated 4/20/2016 indicated EI #1 had a conviction of rape in the 2nd degree. This deficient practice had the potential to affect all 206 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 2/22/2017 indicated the facility had a total of 206 residents. On 2/23/2017 at 9:35 AM, EI #2, the Administrator; EI #3, the Assistant Administrator; EI #4, the Director of Nursing and EI #5, the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy in the area of Resident Rights, F 225. Findings include: On 2/17/2017, the State Agency received an anonymous complaint, which alleged EI #1, a Registered Sex Offender, was working in the facility. The facility's policy titled ABUSE updated 11/28/2016, documented . I. Screening Procedures: 1. Administrator or his designee will review personal and past employment references during the pre-employment process. 2. Summerford Nursing Home, Inc. will conduct on all employees prior to employment: . B. Background check . 3. The application will be given to the Human Resource department with department, shift, and date of hire documented in the upper right hand corner of the application. This documentation from the Administrator or his designee will indicate to all departments, the potential employee has successfully passed all pre-employment screening and that personal and past employment references are satisfactory . Employee Identifier (EI) #1's Application for Employment indicated on 4/19/2016, EI #1 applied for the position of maintenance. On EI #1's application, he indicated he had been convicted of a … | 2020-02-01 |
| 2459 | 2459 | SUMMERFORD NURSING HOME INC | 15075 | 4087 HIGHWAY 31 SOUTHWEST | FALKVILLE | AL | 35622 | 2017-02-23 | 490 | L | 1 | 0 | U6DO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an anonymous complaint received by the State Agency, the facility's administrator's job description, Employee Identifier (EI) #1's Application for Employment and Background Verification Report and staff interviews, the facility's Administrator responsible for the overall management of the facility, and who is responsible for the final approval of all potential hires, approved the hiring of a convicted sex offender to work at the facility. This deficient practice had the potential to affect all 206 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 2/22/2017 indicated the facility had a total of 206 residents. On 2/23/2017 at 9:35 AM, Employee Identifier (EI) #2, the Administrator; EI #3, the Assistant Administrator; EI #4, the Director of Nursing and EI #5, the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy in the area of Administration, F 490. Findings include: On 2/17/2017, the State Agency received an anonymous complaint, which alleged EI #1, a Registered Sex Offender, was working in the facility. The Summerford Nursing Home, Inc. ADMINISTRATOR Job Description documented POSITION PURPOSE Directs operations of Summerford Nursing Home Inc. a 216-bed facility which provides skilled and intermediate care. NATURE AND SCOPE . Hires, . PRINCIPAL ACCOUNTABILITIES *Directs operations of Summerford Nursing Home Inc. to meet State, Federal regulations and avoid violations or licensure decertification . Employee Identifier (EI) #1's Application for Employment indicated on 4/19/2016, EI #1 applied for the position of maintenance. On EI #1's application, he indicated he had been convicted of a crime other than a minor traffic violation. The application listed the crime as sex offender. The Background Verification Report located within EI #1's personnel file and dated 4/20/2016, revealed EI #1 had a guilty plea of felony rape 2nd degree. There was a handwr… | 2020-02-01 |
| 2941 | 2941 | ROBERTSDALE REHABILITATION & HEALTHCARE CTR | 15443 | 18700 U S HIGHWAY 90 | ROBERTSDALE | AL | 36567 | 2016-09-21 | 514 | D | 1 | 0 | BSS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an interview and record reviews, the facility failed to ensure a licensed Nurse documented skin tears to RI (Resident Identifier) #1's arms on 7/3/16, 11 to 7 shift, and the treatment that was provided. This affected RI #1, one of four sampled residents whose charts were reviewed. Findings include: A review of a facility Policy and Procedure titled, Incidents and Accidents, with a revised date of 10/2008, revealed, PURPOSE: The residents environment remains as free of accident hazards as is possible, however when an accident occurs, prompt response and reporting should occur. PR[NAME]ESS: II. Documentation(:) a. Interventions should be documented in the nurse's notes and twenty-four-hour report. A review of RI #1's medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/29/16, revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 10 out of a possible 15 which indicated the resident was moderately impaired for cognitive skills for daily decision making. RI #1 was coded as requiring extensive assistance of 1 person for ADLs (Activities of Daily Living) such as transfers, dressing, toileting, personal hygiene, and bathing. RI #1 was coded on the MDS as occasionally incontinent of urine and always continent of bowel function. A review of RI #1's Nurse's Notes revealed a note dated 7/4/2016 at 1:34 PM, Daughter in visiting her mother and noticed one skin tear to right elbow that had been covered with a Band-Aid and 2 skin tears to left arm, one to left elbow and one just below elbow, resident unable to recall injury to skin, daughter upset and has concerns regarding unreported injuries to her mother's skin and old bruising A review of an Administrative Note dated 7/7/2016 at 1:11 PM revealed, Followed up on concern as to how the skin tears appeared on (RI #1). On the 11p-7a shift of 7… | 2019-09-01 |
| 2940 | 2940 | ROBERTSDALE REHABILITATION & HEALTHCARE CTR | 15443 | 18700 U S HIGHWAY 90 | ROBERTSDALE | AL | 36567 | 2016-09-21 | 157 | D | 1 | 0 | BSS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an interview and record reviews, the facility failed to ensure a licensed Nurse notified RI (Resident Identifier) #1's family member when the resident was found to have skin tears on both arms. This affected RI #1, one of four sampled residents. Findings include: A review of a facility Policy titled, Incidents and Accidents, with a revised date of 10/2008, revealed, PURPOSE: The residents environment remains as free of accident hazards as is possible, however when an accident occurs, prompt response and reporting should occur. PR[NAME]ESS: I. Handling Accident Occurrences (:) . e. Notify family of accident, status and orders for care. A review of RI #1's medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/29/16, revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 10 out of a possible 15 which indicated the resident was moderately impaired for cognitive skills for daily decision making. RI #1 was coded as requiring extensive assistance of 1 person for ADLs (Activities of Daily Living) such as transfers, dressing, toileting, personal hygiene, and bathing. RI #1 was coded on the MDS as occasionally incontinent of urine and always continent of bowel function. A review of RI #1's Nurse's Notes revealed a note dated 7/4/2016 at 1:34 PM, Daughter in visiting her mother and noticed one skin tear to right elbow that had been covered with a Band-Aid and 2 skin tears to left arm, one to left elbow and one just below elbow, resident unable to recall injury to skin, daughter upset and has concerns regarding unreported injuries to her mother's skin and old bruising A review of an Administrative Note dated 7/7/2016 at 1:11 PM, revealed, Followed up on concern as to how the skin tears appeared on (RI #1). On the 11p-7a shift of 7/3/16, the CNA (Certified Nursing Assistant), EI (Employee Id… | 2019-09-01 |
| 1043 | 1043 | PARKWOOD HEALTH CARE FACILITY | 15179 | 3301 STADIUM DRIVE | PHENIX CITY | AL | 36867 | 2017-06-22 | 160 | E | 1 | 0 | B1DM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an interview and review of Resident Identifier (RI) #s ,[DATE]'s trust fund accounts, the facility failed to ensure the remaining balances in the residents' trust fund accounts were returned to the appropriate agency or sponsor within the thirty days following the residents' deaths. This affected four of eight expired residents whose trust funds were reviewed. Three expired residents had funds which should have been returned to the Social Security Administration, and one expired resident had funds which should have been returned to the sponsor. Findings include: On [DATE] a review was conducted of the resident's trust fund accounts managed by the facility. There were four resident accounts whose balances had not been cleared within the thirty mandated disbursement requirement after discharge or death. Resident Identifier (RI) #20 was discharged from the facility to the hospital on [DATE], and the final check was written to clear RI #20's account on [DATE], four days after the thirty day deadline. RI #21 expired on [DATE], but RI #21's account was not cleared until [DATE], 54 days after the thirty day deadline. RI #22 expired on [DATE], but the final disbursement was not made until [DATE], 117 days after the thirty day deadline. RI #23 expired on [DATE], and the clearing of the account was pending as of [DATE]. On [DATE] at 11:10 a.m. (Eastern Daylight Savings Time), an interview was conducted with Employee Identifier (EI) #1 the Administrative Assistant. EI #1 was asked if the trust fund accounts had been cleared for RI #20, 21, 22, and 23. EI #1 stated RI #s 20, 21 and 22's accounts have been cleared but more than thirty days after their death and RI #23's account was still waiting to be cleared. EI #1 was asked if the agency/sponsor should have been paid within the thirty day deadline. EI #1 said Corporate did not want a check sent because the Social Security Administration would take the money out of the accounts electronically … | 2020-09-01 |
| 3356 | 3356 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2016-04-14 | 241 | D | 1 | 0 | 97JR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an observation, interviews, and record reviews, the facility failed to ensure dignity was maintained for RI (Resident Identification) #5 by ensuring the resident was not exposed from waist down during incontinence care, and the privacy curtain was not partially opened on 4/12/16. This deficiency affected RI #5, one of three residents sampled for incontinence care. Findings include: A review of Potter and Perry Fundamentals of Nursing, 7th Edition, Chapter 39, pages 877 and 878 revealed: .Steps . 7. Pull curtain around client's bed . Rationale . Maintain client's privacy and ensures orderly procedure. 12. Fold top bed linen down toward foot of bed, and raise client's gown above genital area. Prepare bed linen to protect client's privacy. a. Diamond drape client by placing bath blanket with one corner between client's legs, one corner pointing toward each side of bed, and one corner over client's chest. Tuck side corners around client's legs and under hips. Rationale . Exposes perineal area for easy accessibility. Prevents unnecessary exposure of body parts and maintains client's warmth and comfort during the procedure. A review of Potter and Perry Fundamentals of Nursing, 7th Edition, Chapter 46, page 1196 revealed: Basic Human Needs . Privacy. Maintain the client's privacy during bowel elimination. A review of the medical record for RI #5 revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of RI #5's Quarterly MDS (Minimum Data Set), dated 2/25/16, revealed RI #5 had a BIMS (Brief Interview for Mental Status) score of 5 out of 15 possible points. This indicated RI #5 had severe cognitive impairment. RI #5 was also coded as always incontinent of bowel and bladder. An observation of incontinence care for RI #5 was done on 4/12/16 at 2:05 PM by two CNAs (Certified Nursing Assistants) EI (Employee Identifier) #1 and EI #2. During the incontinence care, RI #1 was uncovered and exposed fr… | 2019-04-01 |
| 3357 | 3357 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2016-04-14 | 315 | D | 1 | 0 | 97JR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an observations, interviews, and record reviews, the facility failed to ensure Certified Nursing Assistants (CNAs) completely removed stool from RI (Resident Identifier) #3 and RI #5 while providing incontinence care on 4/12/16. This affected RI #3 and RI #5, two of three residents observed for incontinence care. RI #3 had a history of [REDACTED].#5 was recently treated for [REDACTED]. Findings Include: A review of POTTER & PERRY Fundamentals of Nursing, 7th Edition pages 877 and 878, Chapter 39 revealed: Perineal Care . 3. Apply clean gloves, and assess genitals for signs of inflammation, skin breakdown, or infection. Discard gloves. Perform hand hygiene. 6. Prepare necessary equipment and supplies. 7.Assemble supplies at bedside. 8. Raise bed . 9. Apply clean gloves. Rationale . Eliminates transmission of microorganisms. 10. If fecal material is present, enclose in a fold of underpad or toilet tissue, and remove with disposable wipes or tissue. Cleanse buttocks and anus, washing front to back . Cleanse, rinse, and dry area thoroughly. Rationale . Cleansing reduces transmission of microorganisms from anus to urethra or genitalia. 15. Provide perineal care. A. Female perineal care . (2) Fold lower corner of bath blanket up between client's legs and unto abdomen. Wash and dry client's upper thighs. (4) Wash labia majora. Use nondominant hand to gently retract labia from thigh; with dominant hand, wash carefully in skin folds. (5) Separate labia with nondominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubic area toward rectum in one smooth stroke . Cleanse thoroughly around labia minora, clitoris, and vaginal orifice. A review of the medical record for RI #5 revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of RI #5's Quarterly MDS (Minimum Data Set), dated 2/25/16, revealed RI #5 had a BIMS (Brief Interview for Mental Status) score… | 2019-04-01 |
| 761 | 761 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-07-11 | 641 | D | 1 | 1 | F1G011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and a review of the resident's medical record, the facility failed to accurately code Resident Identifier (RI) #140's Discharge Minimum Data Set (MDS) assessment, dated 05/10/19. This deficient practice affected RI #140, one of three residents sampled for closed record review. Findings Include: RI #140 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #140's Discharge Recommendations/Arrangement form, dated 05/10/19, revealed the resident was discharged home. A review of RI #140's Discharge MDS assessment, dated 5/10/19, revealed the resident was discharged to an acute care hospital. On 07/11/19 at 4:09 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON). EI #1 was asked if the Discharge Status section of the MDS dated [DATE] was coded correctly. EI #1 said no. EI #1 was asked what was coded under the Discharge Status section . EI #1 said acute hospital. EI #1 was asked what location was RI #140 discharged to from the facility. EI #1 said home. EI #1 was asked if this was an accurate MDS assessment. EI #1 said no. | 2020-09-01 |
| 3495 | 3495 | GADSDEN HEALTH AND REHAB CENTER | 15180 | 1945 DAVIS DRIVE | GADSDEN | AL | 35904 | 2016-03-10 | 157 | D | 1 | 0 | E8RV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to ensure Resident Identifier (RI) #3's sponsor was notified of changes in skin condition. This affected one of three sampled residents. Findings Include: A review of facility policy titled NOTIFICATION OF PHYSICIAN AND SPONSOR with a review date 3/2010 revealed In event of an .or significant change in the resident's physical, mental or emotional status the attending physician and sponsor will be notified as soon as possible . RI #3 was admitted to the facility 1/3/2013, with [DIAGNOSES REDACTED]. A review of facility forms MARK THE BODY ASSESSMENT AUDIT WITH THE NUMBERS PROVIDED BELOW dated 2/3/16 revealed an area on coccyx marked with # (number) 9 which indicated open area (treatment in place), bilateral heels red and blanches. Further review of skin audits for 2/10/16 and 2/17/16 revealed area on coccyx also marked with #9 which indicated open area (tx in place) and bilateral heels red and blanches. A review of facility form NURSE'S NOTES dated 2/3/16 and 2/17/16 for RI #3 revealed no documentation related to skin changes nor documentation of sponsor notified. On 3/9/16 at 4:40 PM an interview was conducted with Employee Identifier (EI) #2 Licensed Practical Nurse. EI #2 was the nurse that marked the skin audit sheets dated 2/3/16, 2/10/16 and 2/17/16. EI #2 was asked who was responsible for notifying the sponsor of changes in a resident's condition to include skin concerns. EI #2 stated, that would be me or the nurse that found it and if new orders we notify the sponsor to. EI #2 was asked if she notified the sponsor of changes in RI #3's skin, she state, no I did not. On 3/9/16 at 4:00 PM an interview was conducted with EI #1, Director of Nursing. EI #1 was asked if RI #3's family was aware of an open area, she replied she did not know, they should let the family know. EI #1 was asked who is they, she replied the charge nurse as they discover it. EI #1 was asked when should the s… | 2019-03-01 |
| 2868 | 2868 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 250 | J | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to ensure a resident admitted with suicide precautions and who had a history of [REDACTED]. RI #1 was not referred for further treatment. According to the Medical Director the facility failed to notify him for need to evaluate so services could be provided. Resident Identifier (RI) #1's, Hospice Admission information documented RI #1 had a history of [REDACTED]. The facility's policy and procedure for Suicide Prevention directed the staff to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. The policy further directed the staff to contact social services to provide crisis intervention counseling for the resident such as psychological evaluation. Review of RI #1's medical record revealed, from the time the resident was placed on suicide precautions on [DATE], the social worker did not interact with RI #1 until [DATE], nine days after the order was written to place the resident on suicide precautions. The Social Worker failed to put interventions in place, and/or refer the resident to an outside agency for treatment. On [DATE] at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Life, F250. This deficient practice affected, RI #1, one of one sampled resident, who was known to have suicidal ideations. The immediate jeopardy began on [DATE], until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on [DATE] at 5:10 PM. Findings include: The S[NAME]IAL SERVICES Job Description documented . GENERAL PURPOSE OF JOB POSITION .The primary purpose of the job position is to manage the medically related Social Services Program of the facility in accordance with federal, state and local standards, guidelines and regulations and Company policies and p… | 2019-09-01 |
| 3496 | 3496 | GADSDEN HEALTH AND REHAB CENTER | 15180 | 1945 DAVIS DRIVE | GADSDEN | AL | 35904 | 2016-03-10 | 314 | D | 1 | 0 | E8RV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to identify Resident Identifier (RI) #3 with a stage II pressure ulcer as evidenced by skin audit dated 2/3/16, 2/10/16 and 2/17/16. This affected one of three sampled residents. Findings Include: A review of facility policy SUBJECT: Skin assessment and wound care protocol with a review date 1/18/2012 revealed PURPOSE 1. To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown . RI #3 was readmitted to the facility 1/3/2013 with [DIAGNOSES REDACTED]. A review of a facility forms MARK THE BODY ASSESSMENT AUDIT WITH THE NUMBERS PROVIDED BELOW dated 2/3/16 revealed an area on coccyx marked with # (number) 9 which indicated open area (treatment in place), bilateral heels red and blanches. Further review of skin audits for 2/10/16 and 2/17/16 revealed area on coccyx also marked with #9 which indicated open area (tx in place), bilateral heels red and blanches. On 2/20/16 RI #3 was discharged to the hospital. A review of a hospital note dated 2/22/16 revealed Inpatient Consult to Wound/Ostomy Care Team 2/20/16 .Patient came in with .Patient has a stage II on coccyx .Wound measures 7x6x0 is red with darken edges . On 3/9/16 at 3:15 PM an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). The surveyor asked EI #2 to review the skin audits dated 2/3/16, 2/10/16 and 2/17/16 and explain what number 9 identified. EI #2 replied open area. EI #2 was asked what about the heels, she replied red and blanchable. EI #2 was asked if the heels would be considered a pressure ulcer, she replied she did not know. EI #2 was asked to describe a pressure ulcer, she replied a non blanchable it may turn red right on the bone. EI #2 was asked what would the harm be in not identifying an area of pressure. EI #2 replied it could get worse. On 3/9/16 at 4:40 PM EI #2 was asked what would … | 2019-03-01 |
| 3417 | 3417 | CANTERBURY HEALTH CARE FACILITY | 15382 | 1720 KNOWLES ROAD | PHENIX CITY | AL | 36869 | 2016-04-16 | 279 | D | 1 | 0 | I4GD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to develop a care plan for the care of Resident Identifier (RI) #15's Peripherally Inserted Central Catheter (PICC) line. This affected RI #15, one of three residents identified by the facility as having a PICC line. Findings include: RI #15 was readmitted to the facility on [DATE]. RI #15's physician's orders [REDACTED].#15 has PICC line. After review of RI #15's medical record, there was no care plan found to indicate how the staff was to care for RI #15's PICC line. In an interview on 3/22/16 at 3:47 PM, Employee Identifier (EI) #21, the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator was asked should RI #15 have had a care plan to address the care of the resident's PICC line. EI #21 said yes. When asked, why RI #15 did not have a care plan, EI #21 said, I can't tell you why. EI #21 further explained that she missed developing a care plan for RI #15's PICC line. This deficiency was cited as a result of the investigation of complaint/report number AL 343. | 2019-04-01 |
| 3345 | 3345 | MOUNT ROYAL TOWERS | 15455 | 300 ROYAL TOWER DRIVE | BIRMINGHAM | AL | 35209 | 2016-05-12 | 514 | D | 1 | 0 | EOVZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Employee Identifier (EI) #2, a Registered Nurse (RN), documented the administration of medication to Resident Identifier (RI) #1 on 4/23/2016. This affected RI #1, one of three sampled residents. Findings include: RI #1 was admitted to the facility on [DATE], with a medical history to include: Chronic pai[DIAGNOSES REDACTED]. RI #1's physician's orders [REDACTED]. During an interview on 5/12/2016 at 6:40 AM, EI #2, a RN stated she administered Tylenol to RI #1 when the resident had a pain level of 8 on 4/23/2016. When asked, if the [MEDICATION NAME] relieved RI #1's pain, EI #2 stated, yes and further commented that RI #1 slept through the night. RI #1's Visit Note Report from the local hospice agency, indicated on 4/23/2016 at 10:45 PM, a hospice nurse visited RI #1. The note indicated RI #1 was assessed for pain and the resident's pain level was 0, which indicated the resident had no pain. This deficiency was cited as a result of the investigation of complaint/report number AL 388. | 2019-05-01 |
| 3096 | 3096 | DIVERSICARE OF BESSEMER | 15209 | 820 GOLF COURSE ROAD | BESSEMER | AL | 35020 | 2016-07-14 | 514 | D | 1 | 0 | ZW0R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Employee Identifier (EI) #7, a Registered Nurse (RN) documented the administration of medication administered to RI #1 on 6/23/2016 at 8:00 AM. This affected RI #1, one of three sample residents. Finding include: The facility's policy titled Medication Administration General Guidelines dated (MONTH) 2008, documented . Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR following the medication being given . Chapter 26 titled Documentation and Informatics page 352 of FUNDAMENTALS OF NURSING EIGHTH EDITION with a copyright date of 2013, documented . Medication administration Immediately after administration document . RI #1 was admitted to the facility on [DATE] with a medical history to include a [DIAGNOSES REDACTED]. RI #1's physician's orders [REDACTED]. [MEDICATION NAME] Sodium (a laxative medication) Capsule 100 MG (milligram) Give 1 capsule by mouth every 24 hours as needed for constipation . In an interview on 7/14/2016 at 8:15 AM, EI #7, a Registered Nurse (RN) acknowledged she administered [MEDICATION NAME] Sodium to RI #1 on 6/23/2016 at 8:00 AM. When asked, if she documented the administration of this medication, EI #7 replied, no it was not documented on the Medication Administration Record (MAR). EI #7 was asked why was it not documented and she replied that she got distracted. When asked, what was the facility's policy on documentation of medication administration, EI #7 said, sign the MAR after the medication has been administered. EI #7 was then asked, what was the potential harm in not documenting medication administration. EI #7 said, someone could have went behind me and given RI #1 another laxative A review of RI #1's (MONTH) (YEAR) MAR, revealed there was no documentation from EI #7 that a laxative had been administered to the resident on 6/23/2016 at 8:00 AM. This deficiency was cited as … | 2019-07-01 |
| 2283 | 2283 | ASPIRE PHYSICAL RECOVERY CENTER OF WEST ALABAMA | 15465 | 2400 HOSPITAL DRIVE | NORTHPORT | AL | 35476 | 2018-02-14 | 641 | D | 1 | 0 | 3SDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #1's Admission Minimum Data Set (MDS) assessment dated [DATE], was coded accurately to reflect RI #1 received Intravenous (IV) antibiotics during this assessment period. This deficient practice affected RI #1, one of two residents sampled for IV therapy. Findings Include: RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #1's Physician order [REDACTED]. . [MEDICATION NAME] 3.375 GM (grams)/50 ML (milliliter) GALAXY ADMINISTER 3.375 GRAMS DIRECTLY INTO A VEIN (INFUSE OVER IV) EVERY 6 HOURS DX (Diagnosis) VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) . RI #1's Admission MDS assessment, with an Assessment Reference Date of 01/09/18, under Section N - Medications, Medication received: Days: antibiotic, 0 was coded. Under Section O - Special Treatments, Procedures, and Programs, Treatment: IV medications - while a resident, the area was unchecked during this assessment period. A review of RI #1's Electronic Medication Administration Record [REDACTED]. On 02/14/18 at 9:28 a.m., an interview was conducted with Employee Identifier (EI)#5, the Registered Nurse/Case Manager. The surveyor shared with EI #5 that on RI #1's Admission MDS assessment dated [DATE], under Section O, Treatment: IV medications while a resident was unchecked. The surveyor asked EI #5 should it have been checked. EI #5 said yes. The surveyor asked EI #5 what was the timeframe for the look back period under Section O. EI #5 said 14 days. The surveyor asked EI #5 was this assessment an accurate assessment. EI #5 replied, No Ma'am. | 2020-09-01 |
| 290 | 290 | PRATTVILLE HEALTH AND REHABILITATION, LLC | 15065 | 601 JASMINE TRAIL | PRATTVILLE | AL | 36066 | 2019-05-30 | 641 | D | 1 | 0 | X2YW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], identified RI #2 as having a [DIAGNOSES REDACTED]. This deficient practice affected RI #2, one of 10 residents whose MDS assessments were reviewed. Findings Include: RI #2 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #2's Physician order [REDACTED].#2 was ordered the medication [MEDICATION NAME] 10 mg (milligrams) one by mouth daily at bedtime for the [DIAGNOSES REDACTED].#2's (MONTH) 2019 Medication Administration Record [REDACTED]. A review of RI #2's Quarterly MDS assessment, dated 03/04/19, revealed the resident received an antidepressant, but did not identify RI #2 as having a [DIAGNOSES REDACTED]. On 05/30/19 at 8:49 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing. The surveyor asked EI #1 was depression checked as one of RI #2's [DIAGNOSES REDACTED]. EI #1 said she did not see where it had been checked. | 2020-09-01 |
| 2075 | 2075 | HUNTSVILLE HEALTH & REHABILITATION, LLC | 15440 | 4010 CHRIS DRIVE | HUNTSVILLE | AL | 35802 | 2018-11-15 | 657 | D | 1 | 0 | 17UN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #2's care plan was revised and updated to include a fall intervention for a fall mat at the bedside after RI #2 had a fall from the bed on 11/1/2018. This affected RI #2, one of three residents who had falls and whose care plans were reviewed. Findings include: RI #2 was admitted to the facility on [DATE] Review of RI #2's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 10/30/2018, revealed a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognitive skills for daily decision making. This assessment also reflected RI #2 had sustained one fall with no injury since admission, reentry, or prior assessment. A review of RI #2's POST-INCIDENT ACTIONS form dated 11/1/2018 revealed the following: .Immediate Post-Incident Action: . 11/2/18 CPT (care plan team) PLANS TO PLACE MAT FLOOR BESIDE BED. However, review of RI #2's care plan titled POTENTIAL FOR FALLS RELATED TO GENERALIZED WEAKNESS, with a start date of 10/24/2018, did not reflect an intervention of mat at bedside. On 11/15/2018 at 5:10 PM, EI #6, MDS/Care Plan Nurse, was asked who was responsible to place the intervention on RI #2's care plan after RI #2 fell on [DATE]. EI #6 said, she was or the unit manager. When asked why the care plan was not updated after the fall on 11/1/2018, EI #6 said, she could not remember. EI #6 was asked when the care plan should have been updated. EI #6 said, by the next day. When asked what the potential harm was for the care plan not to be updated, EI #6 replied, RI #2 could have another fall and not have anything in place. On 11/15/2018 at 7:35 PM, EI #4, Director of Nursing (DON), was asked why the intervention on RI #2's fall report (fall mat) was not placed on the care plan and the care plan had no new interventions. EI #4 said, It's just not there. It did not get placed on the care plan. … | 2020-09-01 |
| 2574 | 2574 | CHERRY HILL REHABILITATION & HEALTHCARE CENTER | 15445 | 1250 JEFF GERMANY PARKWAY | BIRMINGHAM | AL | 35214 | 2017-01-26 | 274 | D | 1 | 1 | XOWE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was done on Resident Identifier (RI) #13 after declines were identified on the Quarterly MDS dated [DATE], in the areas of personal hygiene and bowel and bladder. The facility further failed to ensure a Significant Change MDS was done on RI #4 after improvements were identified on the Quarterly MDS dated [DATE], in the areas of transfers, dressing, personal hygiene and bowel and bladder. This affected two of 16 sampled residents whose MDS's were reviewed. Findings Include: 1) RI #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #13's Admission MDS, dated [DATE], documented in Section G- Functional Status, RI #13 required supervision with personal hygiene. In Section H- Bowel and Bladder, RI #13 was assessed as only being occasionally incontinent. RI #13's Quarterly MDS dated [DATE], documented in Section G- Functional Status, RI #13 had declined in personal hygiene from supervision to extensive assistance. In Section H- Bowel and Bladder, RI #13 declined from occasionally incontinent to frequently incontinent. On 01/26/17 at 2:45 p.m., Employee Identifier (EI) #1, the MDS/Care Plan Coordinator was asked what warranted a Significant Change MDS. EI #1 replied, it has to be in three or more areas. EI #1 was asked did she compare RI #13's Quarterly MDS to the Admission MDS. EI #1 replied no ma'am. EI #1 was asked why not. EI #1 replied she could not say. EI #1 was asked when comparing RI #13's Quarterly MDS to the Admission MDS did that warrant a Significant Change MDS. EI #1 replied, no ma'am. EI #1 was asked why not. EI #1 replied it was her understanding that it was in one area and that she did not know each section was separate. 2) RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an Assessment Reference Date (ARD) of 06/01/2016, assessed … | 2020-01-01 |
| 2336 | 2336 | ASPIRE PHYSICAL RECOVERY CENTER AT CAHABA RIVER | 15468 | 3070 HEALTHY WAY | VESTAVIA | AL | 35243 | 2018-12-06 | 656 | D | 1 | 0 | 3ES311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a plan of care was developed to address the behavior of resistance to care and turning and repositioning for Resident Identifier (RI) #2. This affected RI #2, one of seven residents for whom care plans were reviewed. Findings include: RI #2 was admitted to the facility on [DATE]. A review of RI #2's Nursing Admission Review dated 9/26/2018, revealed RI #2 had wounds and extensive assistance and at least two person assistance was required for bed mobility on admission. Review of RI #2's nurse's notes revealed the following: .9/28/2018 1:37 AM . Guest request not to be moved tonight. Please I just got comfortable and I don't want to be moved tonight. 10/14/2018 1:31 PM . found supine (lying with his/her back flat on the bed) and repositioned on left side. reenforced to the guest . to stay on (his/her) sides. Review of RI #2's care plans did not reveal any approaches for resident's requests to not be moved or not to be repositioned onto his/her sides. On 12/5/2018 at 3:15 PM, Employee Identifier (EI) #5, CNA (Certified Nursing Assistant), was asked if RI #2 required turning and repositioning. EI #5 said, yes, and RI #2 would say he/she was tired of being on his/her sides and wanted to lie supine. On 12/5/2018 at 4:15 PM, EI #6, CNA, was asked if RI #2 required turning and repositioning EI #6 said, RI #2 was turned if he/she would let them and RI #2 preferred to lay flat on his/her back. On 12/6/2018 at 10:38 AM, EI #4, CNA, was asked about RI #2 having wounds. EI #4 said, RI #2 did not want to be on his/her side and would say no to repositioning constantly. On 12/6/2018 at 10:58 AM, EI #7, Registered Nurse (RN), was asked about RI #2's wound. EI #7 said, it was hard getting RI #2 turned and RI #2 preferred to lay on his/her back. On 12/6/2018 at 4:25 PM, EI #2, Director of Nursing, was asked if RI #2 had a plan of care for not wanting to turn. EI #2 said, no and RI #2 should h… | 2020-09-01 |
| 2907 | 2907 | MCGUFFEY HEALTH & REHABILITATION CENTER | 15202 | 2301 RAINBOW DRIVE | GADSDEN | AL | 35999 | 2016-09-09 | 514 | D | 1 | 0 | DWCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that Resident Identifier (RI) #1's Right BKA (Below Knee Amputation) incision site was documented clearly and concisely to include the presence of staples and the appearance of the incision site. This affected RI #1, one of four residents whose charts were reviewed. Findings include: Potter and Perry's, Fundamentals of Nursing, Eighth Edition, copyright 2013, Chapter 26, pages 348 to 349, document the following: .Documentation is anything written or printed on which you rely as record or proof of patient actions and activities. Documentation in a patient's medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve clinical data, maintain continuity of care, track patient outcomes, and reflect current standards of nursing practice. Information in the patient record provides a detailed account of the level of quality of care delivered to patients. Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors . RI #1 was readmitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. RI #1's Significant Change Minimum Data Set with a reference date of 08/19/2016 documented RI #1 had surgical wound and was receiving surgical wound care. On 08/04/2016 a physician's orders [REDACTED].#1's right extremity at surgical site with wound cleanser, cover and wrap daily. A review of RI #1's physician's orders [REDACTED]. A review of RI #1's Nurses Notes from 08/03/2016 to 08/30/2016 revealed that RI #1 had a right BKA with a dressing and dressing change every day. None of the nurses notes documented the specifics about the right BKA such as appearance of incision site, staples or sutures, healing/not healing, drainage/no drainage. No where in the documentation does it show the resident had staples to the the incision site or how many. Documentation is not… | 2019-09-01 |
| 3000 | 3000 | LAFAYETTE EXTENDED CARE | 15197 | 805 HOSPITAL STREET SOUTHWEST | LAFAYETTE | AL | 36862 | 2016-08-25 | 323 | D | 1 | 0 | 0PIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the mechanical lift was used to transfer Resident Identifier (RI) #1 on 2/14/2016 and 5/19/2016, resulting in two falls for RI #1. This affected one of six residents sampled for the use of mechanical lifts. A review of an undated facility document titled, LAFAYETTE EXTENDED CARE FALL PROT[NAME]OL, revealed, .5. Provide adaptive equipment as needed . A review of an undated facility document titled, LAFAYETTE EXTENDED CARE STANDARDS OF CARE revealed, .8. Immobile residents are dressed .and placed up in a chair via mechanical lift .10. Residents will be assisted with transfer .as needed . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), assessment dated [DATE], revealed RI #1 was totally dependent on staff for transfers and the resident did not move from a seated to a standing position during the assessment period. RI #1's monthly physician orders [REDACTED]. RI #1's Fall careplan documented the resident had a fall in the bathroom on 7/24/2015 and an intervention was added to the careplan to, please use mechanical lift for all transfers. The careplan further revealed RI #1 had a fall in the bathroom on 2/14/2016 and again an intervention was added to the care plan to, please use mechanical lift for all transfers. The careplan also documented another fall on 5/19/2016 in the bathroom/shower room. After this fall, the care plan was updated with the following intervention: Please! Please! use mech (mechanical) lift for all transfers. The facility Incident Report for RI #1's fall on 2/14/2016 was reviewed. The document asked if the incident occurred during a staff assisted transfer and the nurse who filled out the report confirmed it was. There was also a question on the report, Was the transfer method appropriate? The nurse answered this question with No with the following explanation: CNA (Certified Nursing Assistant) was not usin… | 2019-08-01 |
| 3427 | 3427 | CANTERBURY HEALTH CARE FACILITY | 15382 | 1720 KNOWLES ROAD | PHENIX CITY | AL | 36869 | 2016-04-16 | 514 | D | 1 | 0 | I4GD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to obtain a physician's order on 4/8/2016, before changing the route of administration of Resident Identifier (RI) #26's Senna S medication. This deficient practice affected RI #26, one of five residents reviewed for medication availability. Findings include: The facility's policy titled, Prescriber Medication Orders dated 3/2011, documented . 2.3 PRESCRIBER MEDICATION ORDERS . Procedures . 3. Transcription of a physician's order A. A medication order that is documented in resident's medical record with the date by the actual physician/nurse practitioner can be transcribed by non-licensed personnel and verified by a licensed nurse. This order is recorded on the physician's orders and on the Medication Administration Record [REDACTED]. Written transfer orders/readmission orders [REDACTED]. If the order is unclear, incomplete, or a discrepancy is noted, the order should be clarified with the physician and a new order obtained . RI #26 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Transfer Order Medication Profile dated 4/7/2016, indicated RI #29 was ordered to continue [MEDICATION NAME] Sodium (Senna S), one tablet by mouth twice a day. A review of RI #26's eMAR (electronic Medication Record) for (MONTH) (YEAR), revealed RI #26 received Senna S on 4/7/2016 at 9:00 PM and on 4/8/2016 at 9:00 AM. The eMAR further indicated, RI #29's order for Senna S was changed on 4/8/2016 after the medication was administered at 9:00 AM. During an interview on 4/13/2016 at 5:34 PM, Employee Identifier (EI) #27, a Licensed Practical Nurse (LPN), reviewed RI #26's medical record and stated no one had signed off on the order to change RI #26's Senna S on 4/8/2016. In an interview on 4/14/2016 at 2:02 PM, EI #4, the Director of Clinical Education stated, there was no physician's order to change the route of RI #26's Senna S. EI #4 further explained that there should have been a … | 2019-04-01 |
| 3505 | 3505 | VILLAGE AT COOK SPRINGS SKILLED NURSING FACILITY | 15195 | 415 COOK SPRINGS | PELL CITY | AL | 35125 | 2016-03-10 | 206 | D | 1 | 0 | DU6R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to readmit Resident Identifier (RI) #1 after the resident returned to the facility less that 24 hours after being discharged to the Sheriff's Department. This deficient practice affected RI #1, one of six closed records reviewed. Findings include: Page 22 of the VILLAGE AT COOK SPRINGS, LLC SKILLED NURSING FACILITY ADMISSION AGREEMENT dated (MONTH) 2007, documented NOTICE OF HOSPITAL TRANSFER AND BED HOLD AUTHORIZATION . You or your Sponsor may request the Facility to hold a bed open for you while you are absent from the Facility for temporary, medically necessary stays in a hospital or other facility . On 3/4/2016, the State Agency received a complaint which indicated Village at Cook Springs Skilled Nursing Facility, discharged RI #1 on 2/7/2016 and would not readmit the resident on 2/8/2016. RI #1 was originally admitted to the facility on [DATE]. According to RI #1's Face Sheet the resident's payor source was Medicaid. A review of RI #1's medical record revealed a typed letter from the State Project Director addressed to a staff member of Village at Cook Springs dated 11/19/2015 regarding RI #1, which documented In accordance with the federal requirements for Pre-admission Screening for nursing home applicants, I am writing to confirm the results of the attached determination of eligibility. This determination was reached by the results of an evaluation which was recently conducted on the above named individual and indicates that they are: Eligible for continued stay in an Alabama Medicaid Certified Facility. Community based options have been considered, but at this time, their total care needs necessitate the continuous inpatient medical supervision, structure, and intensity that a Nursing Facility provides . The discharge Minimum Data Set ((MDS) dated [DATE] indicated RI #1 had an unplanned discharge to an other location on 2/7/2016 with an anticipated return to the facility. RI… | 2019-03-01 |
| 3251 | 3251 | BROOKDALE UNIVERSITY PARK SNF (AL) | 15423 | 501 UNIVERSITY PARK DRIVE | BIRMINGHAM | AL | 35209 | 2016-06-02 | 281 | D | 1 | 0 | 5X8Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record reviews, the facility failed to ensure Physician's Orders were followed for Resident Identifier's (RI) #1 for [MEDICATION NAME] and RI #3 for [MEDICATION NAME]. This affected two of three sampled residents whose Physician's Ordered were reviewed. Findings Include: The facility policy titled Administering Medications, revised date of (MONTH) 2012 revealed the following:: . Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 3. Medications must be administered in accordance with the orders, including any required time frames . A review of Potter and Perry's Fundamentals of Nursing, Eight Edition, 2013, page 586, documented the following: . Right Documentation. Nurses and other health care providers use accurate documentation to communicate with one another. . If there is any question about a medication order . contact the prescribing health care provider before administering the medication . 1. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed RI #1's Brief Interview for Mental Status Score (BIMS) score of 15, indicating cognition intact. A review of RI #1's hospital discharge (d/c) medication list dated 02/16/16 revealed [MEDICATION NAME] 44 mcg (micrograms)/ (per) 0.5 mL (milliliter) subcutaneous Monday/Wednesday/Friday. A review of the facility's PHYSICIAN/PRESCRIBER PLEASE SIGN AND RETURN, revealed the following: . Telephone Orders . 2/20/16 MEDICATION/Order . [MEDICATION NAME] q (every) M (Monday), W (Wednesday), F (Friday) @ (at) hs (hour of sleep) . A review of RI #1's (MONTH) (YEAR) MAR (Medication Administration Record) revealed RI #1 did not receive a first dose of [MEDICATION NAME] 44 mcg/0.5 mL until 02/22/16. On 06/02/16 at 3:40 PM, during an interview with EI #2, Director of Nursing/DON, the surveyor asked who was … | 2019-06-01 |
| 1494 | 1494 | MONTGOMERY HEALTH AND REHAB, LLC | 15228 | 4490 VIRGINIA LOOP ROAD | MONTGOMERY | AL | 36116 | 2018-02-22 | 656 | D | 1 | 0 | KPEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of Resident Identifier (RI) #1's medical record, the facility failed to develop a comprehensive care plan that addressed the resident's desire to leave the facility and return to the community. This affected RI #1, one of three residents sampled. Findings include: RI #1 was admitted to the facility on [DATE]. RI #1's Social Services Note dated 3/21/2017 1:32 PM, documented . (RI #1's responsible party) agrees that that she does not think the long term setting is appropriate for (RI #1) and wishes the facility could assist in finding placement in a more age appropriate setting . RI #1's Social Services Note dated 5/4/2017 12:08 PM, documented . (RI #1) has discussed with administrator that (he/she) wishes to return back to community . RI #1's Social Services Note dated 6/12/2017 4:39 PM, documented . Resident expressed interest in wanting to live in [MEDICATION NAME] with family close by. RI #1's Quarterly Minimum Data Set with an assessment reference date of 6/15/2017, indicated RI #1 wanted to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. RI #1's Social Services Note dated 6/26/2017 4:47 PM, documented . Spoke with (name) at (local) Association regarding (RI #1) possible placement back in community . RI #1's Social Services Note dated 8/16/2017 10:33 AM, documented . (name) from (local agency) and Ombudsman met with (RI #1) to discuss and complete assessment for referral to transition back to community . RI #1's Quarterly Minimum Data Set with an assessment reference date of 9/14/2017 indicated RI #1 wanted to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. RI #1's Social Services Note dated 9/18/2017 2:42 PM, documented . Contacted (local agency) and (local agency) intake workers to discuss possible qualifications for (RI #1) to return back to community . RI #… | 2020-09-01 |
| 132 | 132 | DIVERSICARE OF FOLEY | 15032 | 1701 NORTH ALSTON STREET | FOLEY | AL | 36535 | 2018-08-04 | 740 | K | 1 | 1 | 5WAU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of Resident Identifier (RI) #49's medical record, the facility failed to identify and address the behavioral health care needs of RI #49, a resident with repeated incidents of resident/resident abuse . On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. Then on 6/26/2018, RI #49 and RI #85 were observed by staff to be pushing each other back and forth and both residents fell to the floor. Refer to F600 The facility further failed to ensure there was a policy/procedure/protocol that directed the staff on how to respond to behaviors and track and trend behaviors to ensure the resident's behavioral care plan was effective in meeting the needs of the resident. RI #49 had documented escalating behaviors; however, the staff responsible for behavior management, Employee Identifier (EI) #12, the Unit Manager/Memory Care Director, was not aware of any systems the facility had in place to monitor RI #49's behaviors. This deficient practice affected RI #49, one of 11 sampled residents reviewed for behaviors, and placed this resident in immediate jeopardy for serious injury, harm or death. This deficient practice had the potential to affect all 20 residents identified by the facility as having behavioral health needs. On 8/2/2018 at 5:08 PM, the facility's Regional Vice President was notified of the findings of immediate jeopardy i… | 2020-09-01 |
| 630 | 630 | MAGNOLIA RIDGE | 15133 | 420 DEAN DRIVE | GARDENDALE | AL | 35071 | 2018-02-01 | 609 | D | 1 | 1 | GYW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of the facility's Abuse Prohibition policy and Resident Identifer (RI) #52's medical record, the facility failed to report injury of unknown source to the State Survey Agency. On 1/4/2018, RI #52, a cognitively impaired resident with no speech, had bruising on the right inner groin area, that continued to spread. Five days later, on 1/9/2018, the bruising was reported to the physician, at which time he ordered X-rays that revealed a fractured femur. This deficient practice affected RI #52, one of one sampled residents reviewed for injuries of unknown source. Findings include: The facility's Abuse Prohibition policy with a revised date of 11/28/2017 documented . The Center will implement an abuse prohibition program through the following: . Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Injuries of unknown source are defined as an injury with both of the following conditions. * The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and * The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time . PR[NAME]ESS . 6. 6.3 Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property not later than two hours after the allegation is made if the event results in serious bodily injury . 6.4 Report allegations involving neglect, exploitation or mistreatment (including injuries or unknown source) and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury . RI #52 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #52 has a medical history to include: Joint Stiffness, Abnormal Posture… | 2020-09-01 |
| 275 | 275 | TERRACE OAKS CARE & REHABILITATION CENTER | 15060 | 4201 BESSEMER SUPER HIGHWAY | BESSEMER | AL | 35020 | 2017-09-10 | 520 | K | 1 | 0 | H93G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview with Employee Identifier (EI) #2, the Director of Nursing, and review of the facility's policy titled Assurance and Performance Improvement (QAPI) Committee, the facility failed to implement an action plan when it was determined routine pain medication ordered for Resident Identifier (RI) #1 was not available in the facility for administration. From 8/25/2017 beginning at 2:00 PM until 8/28/2017 10:00 PM, RI #1 was not administered the ordered pain medication, [MEDICATION NAME], as it was not available; RI #1 missed 11 doses. After EI #2, the DON became aware, she stated she implemented an action plan; however, on 9/1/2017, another resident, RI #2's PRN (as needed) pain medication was not available in the facility for administration when requested. According to EI #2, when the initial action plan was developed, she only spot checked residents ordered pain medication instead of reviewing all residents to determine if all residents' pain medication was available in the facility for administration. This failure to develop and implement a comprehensive action plan to address all failures identified resulted in another resident, RI #2, not having pain medication in the facility for administration when requested. This deficient practice affected RI #1 and RI #2, two of three sampled residents reviewed for availability of pain medication, and placed RI #1 and RI #2 in immediate jeopardy of serious injury, harm or death. On 9/9/2017 at 6:50 PM, the Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Clinical Services and Chief Operating Officer were notified of immediate jeopardy level in the area of Administration, F 520. Findings include: Refer to F 309, F 425 and F 490 The facility's policy titled Assurance and Performance Improvement (QAPI) Committee with an effective date of 4/1/2017, documented Policy Statement This facility shall establish and maintain a Quality Assurance and Performance Im… | 2020-09-01 |
| 274 | 274 | TERRACE OAKS CARE & REHABILITATION CENTER | 15060 | 4201 BESSEMER SUPER HIGHWAY | BESSEMER | AL | 35020 | 2017-09-10 | 490 | K | 1 | 0 | H93G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview with the Director of Nursing (DON) and review of the facility's . Job Description Director of Nursing, the DON, responsible for the overall operation of the Nursing Service Department, failed to ensure the licensed nursing staff implemented the facility's policies so that pain medication was available in the facility for administration to Resident Identifier (RI) #1 and RI #2, when ordered and requested by the resident. RI #1, a resident assessed as having frequent pain, was ordered [MEDICATION NAME] ER (Extended Release) to be administered every eight hours at 6:00 AM, 2:00 PM and 10:00 PM for a [DIAGNOSES REDACTED].#1 was not administered this medication as it was not available in the facility; RI #1 missed 11 doses of routine pain medication. During this time, RI #1 exhibited signs/symptoms of [MEDICATION NAME] withdrawal, to include: complaints of muscle pain, shakiness, nervousness, [MEDICAL CONDITION]/ inability to sleep, and restlessness. RI #2, a cognitively intact resident, assessed as having occasional pain, was ordered [MEDICATION NAME] 10 one tablet by mouth every six hours as needed for pain. RI #2 stated in an interview, the facility ran out of his/her pain medication one time last week for about four to five days. Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN) acknowledged in an interview, that RI #2 requested pain medication once during her shift. EI #11 stated she administered RI #2's last [MEDICATION NAME] 10 on 9/1/2017 and when she returned to work on 9/4/2017, RI #2 did not have any pain medication available for administration. These deficient practices affected RI #1 and RI #2, two of three sampled residents reviewed for pain medication and pharmacy services, and placed RI #1 and RI #2 in immediate jeopardy of serious injury, harm or death. On 9/9/2017 at 6:50 PM, the Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Clinical Services and Chief Opera… | 2020-09-01 |
| 1669 | 1669 | DIVERSICARE OF WINFIELD | 15376 | 144 COUNTY HWY 14 | WINFIELD | AL | 35594 | 2018-05-10 | 600 | D | 1 | 1 | BKT211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, documents titled Alabama Department of Public Health Online Incident Reporting System and Investigation Template and a facility policy titled Abuse Policy, the facility failed to ensure Resident Identifier (RI) #18 was free from physical abuse on 5/3/18. This affected RI #18 one of three residents reviewed for abuse concerns. Findings Include: RI #18 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #18's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/18, documented severely impaired cognitive skills for daily decision making. A review of a policy titled Abuse Policy with an effective date of (MONTH) (YEAR) documented the following: .Abuse means the willful .infliction of injury . with resulting physical harm, pain or mental anguish .Physical abuse includes hitting, slapping, punching and kicking . Policy Statement It is the policy of the center to take appropriate steps to prevent the occurrence of abuse . A review of a document tilted Alabama Department of Public Health Online Reporting System documented: .Incident Type .Physical Abuse .Employee Identifier (EI) 12, Certified Nursing Assistant (CNA) reported RI #18 hit her with his/her shoe. RI #18 was noted to have a bruise and a skin tear to his/her right lower arm . A review of a facility document titled Investigation Template documented: . (RI #18, resident's name) was noted to have a 3 skin tear to right forearm and a 1.5 skin tear to right hand. (RI #18, resident's name) was also noted to have a bruise on right forearm around skin tear .Investigation Summary: .substantiating abuse in the matter . (EI #12, staff's name) will be terminated . A telephone interview was conducted with EI #12, CNA on 5/10/18 at 4:39 p.m. EI #12 stated she went into RI #18's room on 5/3/18 around 9:00 p.m. EI # 12 stated she attempted to change RI #18 and he/she became combative and hit her with a shoe. EI #… | 2020-09-01 |
| 2280 | 2280 | ASPIRE PHYSICAL RECOVERY CENTER AT HOOVER, LLC | 15464 | 575 SOUTHLAND DRIVE | HOOVER | AL | 35226 | 2018-07-03 | 770 | D | 1 | 0 | DT7W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, medical record review and review of a facility policy titled, Diagnostic Testing Services, the facility failed to ensure Resident Identifier (RI) #3's laboratory services were provided timely when orders were received on 05/02/18 to draw the following labs on 05/10/18: Vitamin D Level, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), TSH ([MEDICAL CONDITION] Stimulating Hormone), Free T([MEDICATION NAME]) 4, Free T(Triiodothyronine) 3, Total T3 and Reverse T3. This affected RI #3, one of six residents sampled for laboratory services. Findings Include: On 06/29/18 the State Agency received a complaint indicating RI #3 was not receiving laboratory services as ordered by the physician. In specific that an order for [REDACTED]. RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a facility policy titled, Diagnostic Testing Services dated (MONTH) 10, 2014, documented the following: .Each guest has the right to receive diagnostic services, in a timely manner, to meet his/her needs for diagnosis, treatment and prevention.The physician should be notified . within one day of the results being received, by the facility. Abnormal results prompt an immediate phone call to the physician.3. Lab work and radiology testing results should be reviewed as soon as received. Reports should be filed in the medical record, once the physician has been notified .5. The date, time, physician notified, along with the name and title of the nurse notifying the physician, should be noted on the copy of the test report. On 07/03/18, RI #3's medical record review revealed the following: physician's orders [REDACTED]. No lab results were found for the ordered labs for the specified date. On 07/03/18 at 11:07 p.m., an interview was conducted with Employee Identifier (EI) #1, Registered Nurse(RN)/ Director of Nursing (DON). EI #1 was asked when a lab order was received what steps should be taken. EI #1 said … | 2020-09-01 |
| 895 | 895 | SYLACAUGA HEALTH AND REHAB SERVICES | 15160 | 1007 W FORT WILLIAMS ST | SYLACAUGA | AL | 35150 | 2018-05-22 | 760 | D | 1 | 1 | 1L5311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, medical record review, a facility document titled Incident Report and review of a facility policy titled Medication, Oral/Sublingual Administration, the facility failed to ensure Resident Identifier (RI) # 96 received the correct medication on 5/6/18. This resulted in RI # 96 being sent to the emergency room for an evaluation. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL 689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration with an effective date of 5/2014 documented: Purpose: To administer oral medications in an organized and safe manner . RI # 96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 96's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/18 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated RI # 96 was cognitively intact. A review of an Incident Report dated 5/7/18 documented RI # 96 was found in his/her room around 4:45 a.m. He/she reported I was dizzy and stumbled. I haven't felt right since that nurse gave me that cup full of medicine. RI # 96's skin was pale and clammy. No injuries or pain reported upon assessment. Further review of the incident reported determined RI # 96 received RI # 91's medication on 5/6/18 during the 5:00 p.m. medication pass. On 5/21/18 at 10:51 a.m. an interview was conducted with RI # 96 in his/her room. RI # 96 reported he/she received the wrong medication and was sent to the hospital. RI #96 further stated he/she received blue, yellow, pink and white pills on 5/6/18. A review of RI # 96's current physician's orders [REDACTED].# 96 should have received the following medication by mouth … | 2020-09-01 |
| 893 | 893 | SYLACAUGA HEALTH AND REHAB SERVICES | 15160 | 1007 W FORT WILLIAMS ST | SYLACAUGA | AL | 35150 | 2018-05-22 | 658 | D | 1 | 1 | 1L5311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, medical record review, and review of a facility document titled Incident Report a facility policy titled Medication, Oral/Sublingual Administration and FUNDAMENTALS OF NURSING, NINTH EDITION, the facility failed to ensure a licensed nurse administered the correct medication to Resident Identifier (RI) # 96 on 5/6/18. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL 689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration, with an effective date of 5/2014, documented: Purpose: To administer oral medications in an organized and safe manner . A review of FUNDAMENTALS OF NURSING, NINTH EDITION Chapter 32 Medication Administration, page 625, documented: .Box 32-4 Steps to Take to Prevent Medication Errors *Prepare medications for only one patient at a time *follow the six rights of medication administration (Right Patient, Right Drug, Right Dose, Right Route, Right Time, and Right Documentation) *Be sure to read labels at least 3 times (comparing Medication Administration Record [REDACTED]. RI # 96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 96's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/18 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated RI # 96 was cognitively intact. A review of an incident report dated 5/7/18 documented RI # 96 was found in his/her room around 4:45 a.m. He/she reported, I was dizzy and stumbled. I haven't felt right since that nurse gave me that cup full of medicine. RI # 96's skin was pale and clammy. No injuries or pain reported upon assessment. Further review of the incident reported determined RI # 96 … | 2020-09-01 |
| 664 | 664 | BIRMINGHAM NURSING AND REHABILITATION CENTER EAST | 15134 | 733 MARY VANN LANE | BIRMINGHAM | AL | 35215 | 2017-07-20 | 281 | E | 1 | 0 | J9VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and FUNDAMENTALS of NURSING NINTH EDITION the facility failed to ensure wound treatment was signed off as completed for Resident Identifier (RI) # 1 from (MONTH) 12th - 17th. This occured six of 17 days in (MONTH) and affected one of two residents sampled for wounds. Findings Include: A review of FUNDAMENTALS OF NURSING NINTH EDITION Page 362 documented the following: .Timely entries are essential in a patient's ongoing care .Document the following activities or findings at the time of occurrence .Administration of medications and treatments . RI # 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 1's Electronic Treatment Record (ETAR) dated (MONTH) (YEAR) documented the following treatments: (R) (Right) 5th GREAT TOE WOUND WITH [MEDICATION NAME]. WRAP WITH KERLIX AND ACE BANDAGE FROM FOOT TO KNEES SACRAL [MEDICATION NAME] TO SACRAL WOUND AND FOAM DRESSING, SACRAL [MEDICATION NAME] TO SACRAL WOUND AND FOAM DRESSING, [MEDICATION NAME] TO (R) (Right) FOOT WOUND DAILY, WET TO DRY DRESSING TO SACRAL AREA, CLEAN PLANTAR RIGHT FOOT WITH WOUND CLEANSER. PAT DRY WITH 4X4. APPLY [MEDICATION NAME]. COVER WITH A DRY DRESSING EVERY OTHER DAY and CLEAN AREA TO RIGHT BUTT[NAME]KS WITH WOUND CLEANSER. PAT DRY WITH 4X4. APPLY [MEDICATION NAME]. COVER WITH [MEDICATION NAME] EVERY OTHER DAY . The above treatments were not documented on the ETAR from (MONTH) 12 - 17. An interview was completed on 7/19/17 at 12:00 p.m. with Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), Wound Nurse. EI # 1 was asked about RI #1's ETAR wound treatments for (MONTH) 12 -17. EI # 1 explained the treatments were completed but not documented on the ETAR. EI # 1 was asked what is the importance of showing wound care on the ETAR. EI # 1 replied so you know the order had been carried out. EI # 1 was asked if it should show on the ETAR the treatments were completed. EI # 1 replied yes. On 7/19/17 at 5:0… | 2020-09-01 |
| 665 | 665 | BIRMINGHAM NURSING AND REHABILITATION CENTER EAST | 15134 | 733 MARY VANN LANE | BIRMINGHAM | AL | 35215 | 2017-07-20 | 282 | E | 1 | 0 | J9VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and a facility policy titled CARE PLANS the facility failed to ensure the care plan for Resident Identifier (RI) # 1 was followed concerning completion of wound treatment from (MONTH) 12th -17th. This occurred six of 17 days in (MONTH) and affected one of four residents whose care plans were reviewed. Findings Include: A review of an undated policy titled CARE PLANS documented: .SUBJECT: CARE PLANS .Each resident will have a plan of care to identify problems, needs and strengths, that will identify how the interdisciplinary team will provide care .Care Plan - Contains services provided, preference, ability, and care level guidelines . RI # 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 1's Care Plan documented the following: .Skin integrity 11/06/2012 .Approaches .TX (treatment) per md (medical doctor) orders . A review of RI # 1's Electronic Treatment Record (ETAR) dated (MONTH) (YEAR) documented the following treatments: (R) (Right) 5th GREAT TOE WOUND WITH [MEDICATION NAME]. WRAP WITH KERLIX AND ACE BANDAGE FROM FOOT TO KNEES SACRAL [MEDICATION NAME] TO SACRAL WOUND AND FOAM DRESSING, SACRAL [MEDICATION NAME] TO SACRAL WOUND AND FOAM DRESSING, [MEDICATION NAME] TO (R) (Right) FOOT WOUND DAILY, WET TO DRY DRESSING TO SACRAL AREA, CLEAN PLANTAR RIGHT FOOT WITH WOUND CLEANSER. PAT DRY WITH 4X4. APPLY [MEDICATION NAME]. COVER WITH A DRY DRESSING EVERY OTHER DAY and CLEAN AREA TO RIGHT BUTT[NAME]KS WITH WOUND CLEANSER. PAT DRY WITH 4X4. APPLY [MEDICATION NAME]. COVER WITH [MEDICATION NAME] EVERY OTHER DAY . The above treatments were not documented on the ETAR from (MONTH) 12 - 17. On 7/19/17 at 5:00 p.m. an interview was conducted with Employee Identifier (EI) # 2, Registered Nurse (RN), Director of Nursing (DON). EI # 2 was asked if she felt the care plan was followed concerning RI # 1's wound treatment for [REDACTED]. EI # 2 replied she felt the care plan was followed… | 2020-09-01 |
| 1895 | 1895 | ANDALUSIA MANOR | 15416 | 670 MOORE RD | ANDALUSIA | AL | 36420 | 2018-02-23 | 600 | D | 1 | 1 | FIND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and a review of the facility's policy titled, Abuse Prevention Policy, the facility failed to ensure Resident Identifier (RI) #87 was free from abuse after the facility was made aware of an allegation of verbal abuse involving the resident's room mate, RI #42. This affected RI #87, one of two residents identified for abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention Policy dated 11/28/16, revealed the following: Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . INTERPITATION (INTERPRETATION) . PREVENTION . Observe resident behavior and their reaction to other residents . Place residents in accommodations and environments that keep them calm . React to all allegations . of abuse by residents . Take appropriate actions when abuse . is suspected . PROTECTION . Resident Protection after Alleged Abuse . Examples of ways to protect a resident from harm during an investigation of abuse . may include, but are not limited to: . Temporary (less than 24 hours) separation from other residents if resident's behavior poses a threat of abuse or violence . Protection of . residents from retaliation . A review of an investigative summary submitted to the State dated 02/09/18 regarding resident on resident verbal abuse revealed the following: On 2/4/2018, staff reported that (RI #42) told (RI #87) that it was (his/her) room and (he/she) was going to get up and hit (him/her) as seen in nurses note included for date 2/4/2018. (RI #87) voiced to staff that (he/she) was afraid of (RI #42) . 1. RI #42 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #42's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS also documented R… | 2020-09-01 |
| 2054 | 2054 | HILLVIEW TERRACE | 15436 | 100 PERRY HILL RD | MONTGOMERY | AL | 36109 | 2018-12-20 | 600 | D | 1 | 1 | 5T4011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and a review of the facility's policy titled, Abuse Prevention, the facility failed to ensure Resident Identifier (RI) #107 was free from physical abuse that involved RI #31. This affected RI #107, one of two residents identified for abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention with a revised date of 12/20/18, revealed the following: . III. PREVENTION . 3. residents' rights which include the right to be free of abuse . A review of the State Agency Intake Information, dated 12/06/18, regarding resident on resident physical abuse revealed the following: . Review of a FRI (Facility Reported Incident) received on 12/6/18 revealed that (RI #31) punched (RI #107) in the shoulder and leg . 1. RI #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #31's current Quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #31 had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate impairment in cognition. The MDS also documented RI #31's behavior as physical wandering presence. A review of RI #31's care plan with a problem onset date of 12/06/18, revealed the following: . combative behavior . A review of RI #31's BEHAVIOR/INTERVENTION MONTHLY FLOW RECORD revealed the following: . aggressive/combative w (with)/residents . On 12/19/18 at 8:50 AM, during an interview with RI #31, the surveyor asked did he/she remember an incident on 12/06/18. RI #31 replied, no. The surveyor asked RI #31 if he/she remembered being in the hallway and hitting another resident. RI #31 said no. RI #31 was asked had he/she ever hit another resident or staff. RI #31 said no. 2. RI #107 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #107's Quarterly MDS, dated [DATE], revealed a BIMS score of seven, indicating RI #107 had severe cognitive impairment. The MDS documented no behavior symptoms for RI #107. A review … | 2020-09-01 |
| 2284 | 2284 | ASPIRE PHYSICAL RECOVERY CENTER OF WEST ALABAMA | 15465 | 2400 HOSPITAL DRIVE | NORTHPORT | AL | 35476 | 2018-02-14 | 658 | D | 1 | 0 | 3SDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure Resident Identifier (RI) #1 received Intravenous (IV) antibiotics, [MEDICATION NAME], as ordered by the physician. RI #1 missed three consecutive doses out of the 27 doses of the IV [MEDICATION NAME]. This deficient practice affected RI #1, one of two residents sampled for IV medication therapy. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING, Ninth Edition, with a Copyright date of (YEAR), Chapter 23, Legal Implications in Nursing Practice, page 311, documented: . Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error . RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #1's Physician order [REDACTED]. . [MEDICATION NAME] 3.375 GM (grams)/50 ML (milliliter) GALAXY ADMINISTER 3.375 GRAMS DIRECTLY INTO A VEIN (INFUSE OVER IV) EVERY 6 HOURS DX (Diagnosis) VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) . A review of RI #1's (MONTH) (YEAR) Electronic Medication Administration Record [REDACTED] On 02/14/18 at 9:48 a.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 were the Physician order [REDACTED].#1's medications were not administered as ordered. EI #1 replied, No. | 2020-09-01 |
| 1001 | 1001 | WESLEY PLACE ON HONEYSUCKLE | 15175 | 718 HONEYSUCKLE ROAD | DOTHAN | AL | 36305 | 2017-07-27 | 329 | D | 1 | 1 | HGI511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Antipsychotics, the facility failed to ensure there was a [DIAGNOSES REDACTED].#1 receiving [MEDICATION NAME], an Antipsychotic medication. This deficient practice affected RI #1, one of five residents sampled for the use of Antipsychotic medications. Findings Include: A facility policy titled Antipsychotics, with a date of 03/11, documented: . Procedures 1. Antipsychotics are given only if the resident has been diagnosed with [REDACTED].) and the [DIAGNOSES REDACTED]. RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME] 0.5 mg (milligrams) p.o. (by mouth) BID (twice a day). RI #1's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 05/10/17, under Section N - Medications, revealed RI #1 was identified as having received an Antipsychotic medication during this assessment period. RI #1's (MONTH) (YEAR) physician's orders [REDACTED].> . [MEDICATION NAME] 0.5 MG (milligram) TABLET GIVE 1 TABLET BY MOUTH 2 TIMES A DAY . On 07/27/17 at 2:39 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing. The surveyor asked EI #1, was RI #1 receiving [MEDICATION NAME]. EI #1 said yes. EI #1 said RI #1 was receiving [MEDICATION NAME] 0.5 mg 1 tablet by mouth twice a day. The surveyor asked EI #1 why RI #1 was receiving the [MEDICATION NAME]. EI #1 said she did not know. The surveyor asked EI #1 should there be a [DIAGNOSES REDACTED]. EI #1 replied, Yes. | 2020-09-01 |
| 65 | 65 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 580 | D | 1 | 1 | LZCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Change in Condition: Notification of the facility failed to contact Resident Identifier (RI) # 24's resident representative when his/her diet was changed to pureed in August 2019. This affected 1 of 20 sampled residents. Findings Include: A review of policy titled Change in Condition: Notification of, with an effective date of 11/28/16, documented: .A Center must immediately inform the patient's Health Care Decision Maker (HCDM) where there is:.A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. RI # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI # 24 also had a [DIAGNOSES REDACTED]. A review of RI # 24's diet orders documented the following: 8/13/19.Resident's diet downgraded to pureed due to coughing when eating. Resident appearing at times to have trouble swallowing regular tray. Speech Therapy (ST) was alerted and to see resident. On 03/02/20 at 2:53 p.m. the Surveyor reviewed RI # 24's medical record. A Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 documented the following: . Patient/Caregiver Education = Family/caregiver expressed understanding of evaluation and agreement with goals and treatment plan; Does patient/family agree w/ (with) Diet Recommendation? = Yes. On 3/2/20 at 9:38 a.m. an interview was completed with Employee Identifier (EI) # 3, Speech Therapist. EI # 3 stated she had RI # 24 on her case load on and off in 2019 for swallowing and cognitive problems. EI # 3 was asked what type of diet she recommended for RI # 24. EI # 3 stated she recommended a pureed diet in August of 2019 and RI #24 received that diet after the recommendation. A follow-up telephone interview was completed with EI # 3, Speech Therapist, on 3/2/20 at 2:47 p.m. EI # 3 was asked if she contacted RI #… | 2020-09-01 |
| 56 | 56 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-08-29 | 658 | D | 1 | 1 | 39OM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Medication Orders, the facility failed to ensure Resident Identifier (RI) # 272 received additional [MEDICATION NAME] for three days, as ordered. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Medication Policies Prescriber Medication Orders dated 03/11 revealed the following, Policy Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Procedures 1. Elements of the Medication Order . (4) Time or frequency of administration. RI #272 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. The Physician order [REDACTED].#272, with an order start date of 4/24/19 and a stop date of 4/26/19. The order was to give [MEDICATION NAME] 20 MG (milligram) tablet- take one tablet everyday at noon for three days. On 8/29/19 at 5:52 p.m., the surveyor conducted an interview with Employee Identifier #3, Register Nurse (RN) Unit Manager. The surveyor asked EI #3 was RI #272 admitted to the facility on [MEDICATION NAME] 20 M[NAME] EI #3 stated yes, they were admitted on [MEDICATION NAME] 20 MG daily. The surveyor asked EI #3 when was the RI #272 discharged from the facility. EI #3 stated it looked like he/she was discharged on [DATE]. The surveyor asked EI #3 did he/she receive the [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes they (nursing) were signing off that he/she got the [MEDICATION NAME]. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be started on 4/24/19 and given for three days. EI #3 stated, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated sh… | 2020-09-01 |
| 1760 | 1760 | CROWNE HEALTH CARE OF MONTGOMERY | 15393 | 1837 UPPER WETUMPKA ROAD | MONTGOMERY | AL | 36107 | 2017-12-07 | 842 | D | 1 | 1 | 10XS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Writing, Transcribing & (and) Keying Physician Orders, the facility failed to ensure a Licensed Practical Nurse/LPN, Employee Indentifer (EI) #12, documented accurate information pertaining to Resident Identifier (RI) #262's electronic Treatment Administration Record (eTAR). This deficient practice affected RI #262, one of two residents sampled for dressing change documentation. Finding Include: A review of a facility's policy titled: Writing, Transcribing & (and) Keying Physician order [REDACTED]. . POLICY: 1- Orders are to be taken, recorded and carried out by qualified licensed professional staff within their area of expertise. (RN/LPN) (Registered Nurse Licensed Practical Nurse) . 10-Contents of physician orders [REDACTED]. treatments . The nurse taking the order is responsible for designating the Order type and Time Code. He/She is responsible for taking off the appropriate documentation sheet ( . TAR (treatment administration record) . ) . RI #13 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #262's (MONTH) (YEAR) physician's orders [REDACTED].#262 was to receive: Clean WD (wound) #3 Lt (left) Great Toe Trauma with NS (normal saline) spray pat dry, skin prep, periwound let dry apply Santyl oint (ointment) to wound bed cover with moistened 4 x (by) 4 et (and) secure with lg (large) . qd (every day) / prn (as needed) . The surveyor reviewed RI 262's (MONTH) (YEAR) eTAR (electronic Treatment Administration Record) with the Director Of Nursing, Employee Identifier (EI) #2. EI #2 informed the surveyor that EI #12, LPN, had received an Employee Memorandum, Written Warning for Improper Documentation, Failure to Follow Physician order [REDACTED]. On 12/05/17 at 9:00 a.m., the surveyor observed EI #12, a LPN, was no longer employed at this facility. The surveyor made attempts to contact EI #12 by phone, to inquire… | 2020-09-01 |
| 54 | 54 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-08-29 | 580 | D | 1 | 1 | 39OM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), the facility failed to ensure Resident Identifier (RI) #272's family/responsible party was notified of a new order written on 4/19/19, for [MEDICATION NAME] DR (Delayed Release) 125 MG (milligrams) sprinkle by mouth at hour of sleep. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Change in Medical Condition of Resident/Guest (s), with an effective date of 11/28/2016 revealed the following: .STANDARD: Notification . legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident/guest (s) condition, . *A need to alter treatment . to commence a new form of treatment . RI #272 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #272 Physician order [REDACTED]. The orders also included an order for [REDACTED]. On 8/29/19 5:52 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, Registered Nurse Unit Manager/Supervisor. The surveyor asked EI #3 was there an order for [REDACTED].#3 how could she verify that an order had been given. EI #3 stated what she had been told by this company was that you do not have to have a written order, you can put verbal orders directly into the computer. The surveyor asked EI #3 when did the physician write the order. EI #3 stated she did not know why the physician did not hand write the order. The surveyor asked EI #3 was this a usual practice. EI #3 stated, not generally. The surveyor asked was the family/responsible party notified of the new order. EI #3 stated it did not look like they were notified. The surveyor asked EI #3 where would the evident be that family was notified if there were evident. EI #3 stated in the nurses notes. The surveyor asked EI #3 was there evident in the nurses notes. EI #3 stated t… | 2020-09-01 |
| 2128 | 2128 | SOUTH HAMPTON NURSING & REHABILITATION CENTER | 15448 | 213 WILSON MANN ROAD | OWENS CROSS ROADS | AL | 35763 | 2019-09-05 | 609 | D | 1 | 1 | NJGR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of facility policies tilted Reporting Abuse to State Agencies and other Entities and Abuse Investigation, the facility failed to report an allegation of misappropriation of Resident Identifier (RI) #8's property to the State Agency within 24 hours. This deficient practice was identified during the review of 1 of 3 facility abuse investigative files. Findings Include: A review of a facility policy titled Reporting Abuse to State Agencies and other Entities with a review/ revised date of 11/21/16, documented the following: . All suspected violations, allegations and/or incidents of abuse will be immediately reported to appropriate state agencies . A review of a policy titled Abuse Investigations, with a review/revised date of 5/10/17, documented the following: Type of Allegation . Misappropriation of resident property . 24 hour reporting . A review of a facility file documented an allegation was made against Employee Identifier (EI) #5 on 7/16/19. The allegation alleged EI #5 took resident Identifier (RI) #8's medication [MEDICATION NAME]. An interview was conducted with EI #4, Registered Nurse (RN) / Director of Nursing (DON)/ Abuse Coordinator, on 9/5/19 at 2:00 p.m EI #4 was asked when she was made aware of the allegation that EI #5 took RI #8's medication. EI #4 stated three CNA's came to her on 7/16/19. EI #4 was asked why this was not considered an allegation of abuse. EI #4 stated because she knew there was a rift between the parties involved. EI #4 was asked if taking someone's medication would be considered misappropriation of resident property. EI #4 stated, absolutely. EI #4 was asked if the allegation was reported to the State Agency. EI #4 stated, no. EI #4 was asked if she completed an investigation, why the findings were not reported. EI #4 stated it never crossed her mind that it would be reportable. EI #4 was asked if this allegation should have been reported to the State Agency. E… | 2020-09-01 |
| 2334 | 2334 | ASPIRE PHYSICAL RECOVERY CENTER AT CAHABA RIVER | 15468 | 3070 HEALTHY WAY | VESTAVIA | AL | 35243 | 2018-12-06 | 641 | D | 1 | 0 | 3ES311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy titled, Resident Assessment Instrument (RAI), the facility failed to ensure Resident Identifier (RI) #2's Admission Minimum Data Set (MDS) assessment was coded in the bowel and bladder section to include the use of a urinary Foley Catheter (F/C). This affected RI #2, one of four residents whose MDS was reviewed. Findings include: Review of a facility policy titled, Resident Assessment Instrument (RAI) with an effective date of 10/29/2015, revealed the following: PURPOSE: Residents are assessed, . in order to identify care needs . STANDARD: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate . assessment of each resident's functional capacity, . RI #2 was admitted to the facility on [DATE]. RI #2's Nursing Admission Review, dated 9/26/2018, revealed RI #2 had a urinary F/C present upon admission. A review of RI #2's admission Charge nurse note, dated 9/26/2018 at 8:09 PM, revealed RI #2 had a F/C in place draining clear yellow urine. A review of RI #2's nurse's notes revealed the following notations for the presence of a F/C: . 9/27/2018 7:29 PM . Guest . has a foley. 9/28/2018 1:37 AM . foley cath in place draining clear yellow urine. 9/28/2017 5:23 PM . Guest has a foley draining clear amber urine. 9/29/2018 11:14 AM . Guest has a foley draining clear amber urine. 9/30/2018 10:36 AM . Guest has a foley draining clear amber urine. 10/1/2018 9:42 PM . Guest has foley draining clear amber urine. 10/3/2018 1:00 PM . with foley . Review of the bowel and bladder section of RI #2's admission MDS assessment, with an Assessment Reference Date (ARD) of 10/3/2018, revealed indwelling catheter was unchecked and RI #2 was instead, coded as always incontinent of bladder. On 12/6/2018 at 6:05 PM, Employee Identifier (EI) #3, MDS Coordinator was asked if the bowel and bladder section of the MDS should be coded for a resident with a … | 2020-09-01 |
| 507 | 507 | RIVER CITY CENTER | 15113 | 1350 FOURTEENTH AVENUE SOUTHEAST | DECATUR | AL | 35601 | 2019-08-22 | 658 | D | 1 | 0 | LPYD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and the facility's policy titled NSG241 Treatments, the facility failed to provide evidence of Resident Identifier (RI) #1's wound care treatments being provided, according to physician orders. This deficient practice affected RI # 1, one of two resident whose Physician order [REDACTED]. The facility's policy titled, NSG241 Treatments, revised date 11/28/19, revealed, Policy A licensed nurse or medical technician, per state regulations, will perform ordered treatment. Accepted standard of practice will be followed. 9. Document: 9.1 Administration on Treatment Administration Record. RI #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of RI #1's physician's orders [REDACTED]. The order was to clean the left toe with Vashe, cover with wet to dry dressing and wrap with Kerlix dressing daily and as needed. A review of RI #1's Treatment Administration Records (TAR), with a start date of 7/25/19, revealed no initials documented for 7/25/19-7/27/19, to indicate that wound treatment was provided to the toe. On 8/22/19 at 3:36 p.m., the surveyor conducted an interview with a Registered Nurse, Employee Identifier (EI) #4. The surveyor asked EI #4 how would the surveyor know RI #1's wound care dressing was done, according to the TAR. EI #4 said she did it and forgot to sign it off. EI #4 was asked when documenting during her shift, where could the surveyor find the evidence the wound care was done. EI #4 said she would have signed the TAR, she just forgot to sign it off. EI #4 was asked when working with RI #1 had the resident refused wound care. EI #4 said no, she had only worked with EI #1 a few times. | 2020-09-01 |
| 1897 | 1897 | ANDALUSIA MANOR | 15416 | 670 MOORE RD | ANDALUSIA | AL | 36420 | 2018-02-23 | 609 | D | 1 | 1 | FIND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, a review of the facility's policy titled, Abuse Prevention Policy, the facility failed to ensure an allegation of verbal abuse was reported with the two hour time frame. This affected Resident Identifier (RI) #42 and RI #87, two of two residents identified for Abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention Policy dated 11/28/16, revealed the following: Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . REPORTING/RESPONSE . Prohibit and prevent retaliation. In response to allegations of abuse, . the facility must: Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made . Prevent further potential abuse, . while the investigation is in process . A review of an investigative summary submitted to the State dated 02/09/18, regarding resident on resident verbal abuse revealed the following: On 2/4/2018, staff reported that (RI #42) told (RI #87) that it was (his/her) room and (he/she) was going to get up and hit (him/her) as seen in nurses note included for date 2/4/2018. (RI #87) voiced to staff that (he/she) was afraid of (RI #42) . 1. RI #42 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #42's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS also documented RI #42's behavior as physical behavior symptoms directed toward others. A review of RI #42's care plan with a problem onset of 02/01/16 revealed the following: .is easily agitated with . residents.( He/She) becomes combative (kicking, hitting, biting) . (He/She) cusses . 2. RI #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #87's… | 2020-09-01 |
| 415 | 415 | CROWNE HEALTH CARE OF MOBILE | 15100 | 954 NAVCO ROAD | MOBILE | AL | 36605 | 2018-02-15 | 659 | D | 1 | 0 | DFKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled Care Planning Policy and Procedure, the facility failed to ensure Resident Identifier (RI) # 1's plan of care to have two people assist with Activities of Daily Living (ADLs) was followed. This deficient practice affected RI #1, one of three sampled residents for whom the the plan of care was reviewed. Findings Include: Review of a facility policy titled Care Planning Policy and Procedure, with a revised date of 07/2011, documented: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being . RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's comprehensive care plans included a plan for . Resident at risk for falls due to immobility, lack of safety awareness and requires . 2 person assist for transfers with a Problem Onset date of 2/15/2013. This care plan indicated RI #1 required two person assistance for repositioning. A Yearly Minimum Data Set assessment, with an Assessment Reference Date of 10/10/2017, documented RI #1 was totally dependent on two plus staff members for bed mobility, transfers, dressing, toileting, and bathing. On 12/12/2017 the state agency received an anonymous complaint alleging RI #1 sustained a fracture when the facility staff dropped him/her. The facility told the complainant they would complete an investigation into the occurrence. Review of the facility's investigative summary related to the incident involving RI #1, dated 12/01/2017, revealed the following: .Our investigation determined that at approximately 11:30 a.m. during morning care on 11/26/17, (Employee Identifier (EI) #5, Certified Nursing Assistant) C.N.[NAME] noted (RI #1) to be screaming out when touched as well as swelling to left arm. This was reported to (EI #4, Licensed Practical Nurse), LPN and upon observation from the nurs… | 2020-09-01 |
| 497 | 497 | RIVER CITY CENTER | 15113 | 1350 FOURTEENTH AVENUE SOUTHEAST | DECATUR | AL | 35601 | 2017-05-11 | 157 | D | 1 | 1 | RO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's Beneficiary Notification Process, the facility failed to ensure timely notification of RI (Resident Identifier) #1's representative of a change in pay source for RI #1 in (MONTH) (YEAR). This deficient practice affected one of 18 sampled residents. Findings Include: 1. A review of the Beneficiary Notification Process revealed the following: .NOTICE OF MEDICARE NON-COVERAGE . PART 1A . What is Expedited Determination? . SNFs (Skilled Nursing Facilities) must: * Provide a Notice of Medicare Non-Coverage to Medicare beneficiaries no later than two days before the effective date their Medicare coverage ends . RI #1 was admitted to the facility on [DATE]. A review of RI #1's SNF DETERMINATION ON CONTINUED STAY dated 9/29/2016 revealed the following: . On 09/29/2016 ., we reviewed your medical information and found that the services furnished . (RI #1) . no longer qualified as covered under Medicare beginning 10/03/2016 . A review of the form titled REQUEST FOR MEDICARE INTERMEDIARY REVIEW dated 10/5/2016, revealed the following: . D. This is to confirm that you were advised of the non-coverage of the services under Medicare by telephone on 10/5/16 . (Name of Beneficiary or Representative (rep) contacted) . The form was signed by RI #1's Financial Power of Attorney. A review of RI #1's Notice of Medicare Non-Coverage revealed the following: The Effective Date Coverage of Your Current: SKILLED NURSING Services will End: 10/02/2016 . I delivered this notice telephonically to . (rep's name), authorized representative for (RI #1) . on 10/5/16 at 3:43 pm. I explained that the last covered day will be 10/02/2016. Center Representative Signed, (EI (Employee Identifier) #2) 10/5/16 . On 5/11/2017 at 10:25 a.m. EI #2, Accounts Receivable Bookkeeper, was asked about the facility policy for Notification of Medicare Non-Coverage. EI #2 said, she was supposed to provide notification 48 hours prio… | 2020-09-01 |
| 920 | 920 | CHOCTAW HEALTH AND REHAB | 15164 | 1406 EAST PUSHMATAHA STREET | BUTLER | AL | 36904 | 2018-03-01 | 609 | D | 1 | 1 | X95711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of a facility policy titled ABUSE/REPORTING and review of the Alabama Department of Public Health Online Incident Reporting System, the facility failed to ensure an allegation of physical abuse was reported to the State Survey Agency within a two hour time frame when RI #76 hit RI #41 on 12/27/17. This deficient practice affected Resident Identifier (RI) #41 and RI #76, two of two residents reviewed for Facility Reported Incidents. Finding Include: A facility policy titled ABUSE/REPORTING, dated (MONTH) (YEAR), documented . Reporting/Documentation Requirements Ensure that all alleged violations involving abuse . are reported to the administrator of the center and to other officials (including to the State Survey Agency .) in accordance with State law through established procedures in these timeframes: If the event that cause the allegation involve abuse . the event must be reported immediately, but no later than 2 hours after the allegation is made . RI #41 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/17/18, assessed RI #41 to score a 6 on the Brief Interview for Mental Status (BIMS) indicating RI #41 had severely impaired cognition. RI #76 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Significant Change MDS assessment, with an ARD of 01/21/18, assessed RI #76 to score a 3 on the BIMS indicating RI #76 also had severely impaired cognition. A review of the Alabama Department of Public Health Online Incident Reporting System documented: . Date/Time Submitted: Wednesday, (MONTH) 27, (YEAR) 5:42 . PM . Incident Type . Physical Abuse . Date and time of incident or alleged incident: 12/27/2017 Time: 02:17 PM Narrative summary of incident: (RI #76) hit (RI #41) due to becoming agitated when (RI #41) did not move his/her w/c (wheelchair) fast e… | 2020-09-01 |
| 183 | 183 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 490 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility Abuse Policy, and review of the facility Position Description for the Director of Nursing (DON), the DON failed to implement the facility abuse policy and report to the state agency, an allegation of abuse made to her on 11/14/2017. RI (Resident Identifier) #3's family reported to the DON, EI #1 that RI #3 had been left in bowel movement (BM) for a long time. This affected one of three residents sampled for abuse concerns. On the afternoon of 11/14/2017 the state agency received a complaint that a CNA (Certified Nursing Assistant), on 11/13/2017, refused to change RI #3, ignored the resident's request to be changed, and put RI #3 to bed without providing incontinent care. Findings Include: A review of an undated facility Position Description for Director of Nursing revealed the following: . KEY RESPONSIBILITIES . 1. Implements policies/procedures with follow up . 7. Ensures positive outcomes are accomplished for residents; . A review of the facility policy titled Abuse Policy with an effective date of 2/2017 documented the following: . POLICY STATEMENT It is the policy of the center . to ensure that all alleged violations . which involve mistreatment, neglect, abuse, . will also be reported to state agencies . Reporting All alleged violations involving mistreatment, neglect, abuse, . are reported immediately to . officials in accordance with State law . Every attempt will be make to report: 1. Any allegation of abuse within two hours and . 3. Other allegations of neglect, mistreatment, .without serious injury within 24 hours . RI #3 was admitted to the facility on [DATE]. A review RI #3's Concern/Grievance form documented the following information was received by EI (Employee Identifier) #1, DON (Director of Nursing) on 11/14/2017: . left in BM (bowel movement) for a long time . On 11/16/2017 at 10:30 a.m. EI #1 was asked how she received the grievance concern about RI #3. EI #1 said… | 2020-09-01 |
| 184 | 184 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 514 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, and review of the facility policy titled ADMINISTRATION PR[NAME]EDURES FOR ALL MEDICATIONS the facility failed to ensure documentation was completed and accurate for RI (Resident Identifier) #4 on the MAR (Medication Administration Record) and accurately reflected medication as it had been administered. This affected one of three residents sampled for review of the MAR. Findings Include: Review of the facility policy titled ADMINISTRATION PR[NAME]EDURES FOR ALL MEDICATIONS dated 6/15 documented the following: . Procedures . [NAME] After administration, return to cart, . and document administration in the MAR . RI #4 was admitted to the facility on [DATE]. A Physican's order, dated 10/12/17, instructed the facility to give two Tylenol Extra Strength Tablet 500 milligram tablets by mouth every 4 hours for 2 days until the [MEDICATION NAME] medication was delivered. A review of RI #4's (MONTH) (YEAR) MAR indicated [REDACTED]. However, on 10/13/17, the dose scheduled for 2:00 p.m. dose was left blank and not documented as administered. On 11/18/2017 at 5:30 p.m. EI (Employee Identifier) #5 LPN (Licensed Practical Nurse) was asked why there was a blank on the MAR. EI #5 said, she did not know how that happened but she knew if it was not signed it was not done. When asked what documentation there was to show the medication had been administered, EI #5 said, there was not any for 2:00 p.m | 2020-09-01 |
| 181 | 181 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 323 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, and review of the facility policy titled Falls the facility failed to ensure Resident Identifier (RI) #4, a resident identified as a fall risk, had prevention measures in place prior to sustaining a fall on 10/1/2017. Further, the facility failed to ensure the fall was investigated to include witness statements of staff who last observed RI #4 prior to the fall, and causal factors for the fall. This affected one of three residents sampled for fall concerns. On 11/1/2017 the state agency received a complaint that alleged RI #4 had a fall on 10/1/2017, the facility was aware the resident was at risk for falls, and the bed should have been in the low position and was not. The complainant stated the facility did not say what had caused the fall. Findings Include: A review of the facility policy titled Falls, dated (MONTH) (YEAR), documented the following: Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. Process On admission . When a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed . Post fall . A fall huddle is called to help in investigating circumstances around the fall and help determine immediate interventions . RI #4 was admitted to the facility on [DATE]. A review of a facility form for RI #4 titled Clinical Health Status Evaluation with an effective date of 9/15/2017, the day of admission, documented risk factors with Yes answers for RI #4 that included: gait/balance impairment, impairment of lower extremity strength, medication risks, and the resident displayed one or more of the following (restlessness, lethargy, wandering, resistive to care). The form also documented the following: . Any Yes answer indicates Fall Risk - Proceed to Care Plan . A review of RI #4's fall report dated 10/1/2017 documented: . Incident Description . Summoned to room, resident observed lying… | 2020-09-01 |
| 2333 | 2333 | ASPIRE PHYSICAL RECOVERY CENTER AT CAHABA RIVER | 15468 | 3070 HEALTHY WAY | VESTAVIA | AL | 35243 | 2018-12-06 | 635 | D | 1 | 0 | 3ES311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, and review of the facility policy titled, Admission Physician's Orders, the facility failed to ensure an order for [REDACTED]. This affected RI #2, one of four residents for whom admission orders [REDACTED] Findings include: Review of a facility policy titled, Admission Physician's Orders with an effective date of 7/21/2011, revealed the following: PURPOSE: Admission Physician's Orders provide documentation of the Physician's Plan of Care at the time of admission. STANDARD: The Physician's Plan of Care on admission may include the following: . Treatments . PR[NAME]ESS: I. Orders from the Transfer Sheet from another health care facility should be handled as follows: a) Transcribe into the medical record; double-check for accuracy . RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's Nursing Admission Review dated 9/26/2018, revealed a urinary F/C was present on admission. RI #2's Nursing Admission Review was completed by Employee Identifier (EI) #1, Licensed Practical Nurse (LPN). A review of RI #2's admission charge nurse note, dated 9/26/2018 at 8:09 PM, revealed RI #2 had a F/C in place draining clear yellow urine. RI #2's admission charge nurse note was signed by EI #1. RI #2's admission orders [REDACTED]. On 12/6/2018 at 3:00 PM, EI #1 was asked what physician orders would routinely be written for the use of a F/C. EI #1 said, to check for drainage, assess the perineal area for redness, pain, and burning. EI #1 was asked why RI #2 did not have an order for [REDACTED].#1 thought medical records was responsible for physician orders on new admissions. On 12/6/2018 at 4:25 PM, EI #2 Director of Nursing (DON), was asked who was responsible for obtaining a physician order for [REDACTED].#2 said, the nurse who saw the F/C in place should have notified the CRNP (Certified Registered Nurse Practitioner) of the need for the physicians order. EI #2 said, there shou… | 2020-09-01 |
| 182 | 182 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 425 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, and review of the facility policy titled, Medication Ordering and Receiving From Pharmacy the facility failed to ensure Resident Identifier (RI) #4's pain narcotic mediation was available in the facility before supply was exhausted. This affected one of three residents sampled for pain. Findings Include: A review of the facility policy titled Medication Ordering and Receiving From Pharmacy dated 6/15 documented the following: . Procedures [NAME] 2) . d. The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions for use . RI #4 was admitted to the facility on [DATE]. RI #4's progress note dated 10/7/2017 documented: . change Norco 10/325mg (milligram) . to every 4hrs (four hours) routine. A facility form titled Controlled Substance Accountability Sheet for RI #4 documented a dose of Norco administered on 10/12/2017 at 2:00 a.m. left RI #4 with a balance of zero and the supply was exhausted. On 11/18/2017 at 5:30 p.m. EI #5 LPN (Licensed Practical Nurse) was asked why RI #4's Norco supply ran out. EI #5 said, the dosage was changed. EI #5 was asked what system failed. EI #5 said, a script should have been obtained in a timely manner and faxed to the pharmacy. When asked who was responsible for ensuring residents medication did not run out, EI #5 said, we all are as a team. RI #5 was asked why it was important to make sure prescriptions were obtained and medications ordered timely. EI #5 said, the resident may be in pain and for continuity of medication. | 2020-09-01 |
| 2335 | 2335 | ASPIRE PHYSICAL RECOVERY CENTER AT CAHABA RIVER | 15468 | 3070 HEALTHY WAY | VESTAVIA | AL | 35243 | 2018-12-06 | 655 | D | 1 | 0 | 3ES311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, and review of the facility policy titled, Person Centered Care Plans, the facility failed to ensure Resident Identifier (RI) #2's initial care plan upon admission to the facility on [DATE], included the use of and care required for, a urinary Foley Catheter (F/C). This affected one of seven residents whose admission care plans were reveiwed. Findings include: Review of a facility policy titled, Person Centered Care Plans, with an effective date of (MONTH) 15, (YEAR), revealed the following: . STANDARD: According to federal regulations, the facility develops and implements a baseline plan of care within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident/guest . RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #2's Nursing Admission Review dated 9/26/2018, revealed a urinary F/C was present on admission. RI #2's Nursing Admission Review was completed by Employee Identifier (EI) #1, Licensed Practical Nurse (LPN). A review of RI #2's admission charge nurse note, dated 9/26/2018 at 8:09 PM, revealed RI #2 had a F/C in place draining clear yellow urine. RI #2's admission charge nurse note was signed by EI #1. A review of RI #2's care plans revealed there was not a care plan developed for the use of a F/C. On 12/6/2018 at 3:00 PM, Employee Indentifer (EI) #1 was asked who was responsible for completing the care plans for baseline needs upon admission. EI #1 said, she was. The areas that EI #1 completed were reveiwed with EI #1 and there was not a plan of care for a urinary F/C. When asked if F/C care should have been included in the baseline plan of care, EI #1 said, yes. On 12/6/2018 at 4:25 PM, EI #2, Director of Nursing, was asked if a urinary F/C would be an immediate need. EI #2 said, yes. When asked if it should have been included in the baseline plan of care, EI #2 said, y… | 2020-09-01 |
| 180 | 180 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 279 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, and the facility policy titled Falls the facility failed to ensure a plan of care, with individualized approaches to prevent falls, was developed for Resident Identifier (RI) #4, a resident who was at risk of falling. RI #4 sustained a fall on 10/1/2017. This affected one of three residents sampled for fall concerns. Findings Include: A review of the facility policy titled Falls, dated (MONTH) (YEAR) documented the following: . Process On admission . When a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed. When the risk is identified the intervention is documented on the care plan . The identified intervention is initiated. RI #4 was admitted to the facility on [DATE]. A review of a facility form for RI #4 titled Clinical Health Status Evaluation with an effective date of 9/15/2017, the day of admission, documented risk factors with Yes answers for RI #4 that included: gait/balance impairment, impairment of lower extremity strength, medication risks, and the resident displayed one or more of the following (restlessness, lethargy, wandering, resistive to care). The form also documented the following: . Any Yes answer indicates Fall Risk - Proceed to Care Plan . A review of RI #4's earliest care plan for falls documented Focus . Fall R/T (related to) weakness: observed on floor this evening. Date Initiated: 10/01/2017 . On 11/18/2017 at 4:20 p.m. EI (Employee Identifier) #1, DON (Director of Nursing) was asked if RI #4 was found to be as risk for falls. EI #1 said, based on RI #4's Admission Clinical Health Status Evaluation RI #4 could be at risk for falls. EI #1 was asked if a care plan was developed. EI #1 said, it should have been on admission. On 11/18/2017 at 5:35 p.m. EI #1 was asked if there was an initial plan of care for falls for RI #4. EI #1 replied, there was not a care plan found from before 10/1/2017. When asked why it would be … | 2020-09-01 |
| 178 | 178 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 226 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, review of the facility policy titled Abuse Policy, and review of a facility form titled Customer Concern/Grievance Communication Form the facility failed to ensure the abuse policy implemented when an allegation of abuse was made to the facility by a resident's family on 11/14/2017. The allegation was not reported to the state agency. This affected RI (Resident Identifier) #3, one of three residents sampled for abuse concerns. On the afternoon of 11/14/2017 the state agency received a complaint that a CNA (Certified Nursing Assistant), on 11/13/2017, ignored RI #3's request to be changed and put RI #3 to bed without providing incontinent care. Findings Include: A review of the facility policy titled Abuse Policy with an effective date of 2/2017 documented the following: . POLICY STATEMENT It is the policy of the center . to ensure that all alleged violations . which involve mistreatment, neglect, abuse, . will also be reported to state agencies . Reporting All alleged violations involving mistreatment, neglect, abuse, . are reported immediately to . officials in accordance with State law . Every attempt will be make to report: 1. Any allegation of abuse within two hours and . 3. Other allegations of neglect, mistreatment, .without serious injury within 24 hours . RI #3 was admitted to the facility on [DATE]. A review RI #3's Concern/Grievance form documented the following information was received by EI (Employee Identifier) #1, DON (Director of Nursing) on 11/14/2017: . left in BM (bowel movement) for a long time . On 11/16/2017 at 10:30 a.m. EI #1 was asked how she received the grievance concern about RI #3. EI #1 said, on the early morning of 11/14/2017 at about 6:00 a.m. RI #3's family was brought to her office to report concerns. When asked what the family reported about RI #3 being left in BM, EI #1 stated, RI #3 was left in BM for a long time. On 11/17/2017 at 2:45 p.m. EI #1 was asked what … | 2020-09-01 |
| 177 | 177 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 225 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, review of the facility policy titled Abuse Policy, and review of a facility form titled Customer Concern/Grievance Communication Form the facility failed to report to the state agency an allegation of abuse reported to the facility on [DATE], by a resident's family. This affected RI (Resident Identifier) #3, one of three residents sampled for abuse concerns. Findings Include: A review of the facility policy titled Abuse Policy with an effective date of 2/2017 documented the following: . POLICY STATEMENT It is the policy of the center . to ensure that all alleged violations . which involve mistreatment, neglect, abuse, . will also be reported to state agencies . Reporting All alleged violations involving mistreatment, neglect, abuse, . are reported immediately to . officials in accordance with State law . Every attempt will be make to report: 1. Any allegation of abuse within two hours and . 3. Other allegations of neglect, mistreatment, .without serious injury within 24 hours . RI #3 was admitted to the facility on [DATE]. A review RI #3's Concern/Grievance form documented the following information was received by EI (Employee Identifier) #1, DON (Director of Nursing) on 11/14/2017: . left in BM (bowel movement) for a long time . On 11/16/2017 at 10:30 a.m. EI #1 was asked how she received the grievance concern about RI #3. EI #1 said, on the early morning of 11/14/2017 at about 6:00 a.m. RI #3's family was brought to her office to report concerns. When asked what the family reported about RI #3 being left in BM, EI #1 stated, RI #3 was left in BM for a long time. On 11/17/2017 at 2:45 p.m., EI #1 was asked what should happen according to the facility policy when someone makes an allegation of abuse, EI #1 stated, to call the administrator, determine if reportable and report to the Alabama Department of Public Health. EI #1 was asked if she considered being left in BM abuse. EI #1 replied, it depe… | 2020-09-01 |
| 1763 | 1763 | COLONIAL HAVEN CARE & REHABILITATION CENTER | 15396 | 616 ARMORY STREET | GREENSBORO | AL | 36744 | 2018-03-01 | 573 | D | 1 | 1 | MZGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, resident record review, review of the facility policy titled Release of Information and review of the facility form titled Resident Rights, the facility failed to provide medical records to RI (Resident Identifier) #134's sponsor within 30 days as requested. This affected one of 4 residents sampled for access to medical records. The State Agency received a complaint on 11/14/2017 alleging RI #134's medical records had not been released to RI #134's estate executor within 30 days as ordered by a judge. Findings include: A review of the facility policy titled Release of Information with an effective date of 1/1/2016 revealed the following: . 3. All information contained in the resident's medical record . may only be released by the written consent of the resident or his/her legal representative . 10. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight . hour . advance notice of such request. Review of a facility form titled . Resident Rights documented the following: . (g)(2)(ii) The facility must allow the resident to obtain a copy of the records or any portions thereof . upon request and 2 (two) working days advance notice to the facility. RI #134 was readmitted to the facility on [DATE] and discharged on [DATE]. RI #134's medical record request file was reviewed and contained documentation as follows: Documentation was reviewed from the county probate court/judge dated 10/2/2017 that granted RI #134's responsible party as administrator of the resident's estate. A copy of a medical record request dated 10/11/2017, from RI #134's estate executor to the facility, requested copies of the complete medical chart for the dates (MONTH) (YEAR) through (MONTH) 2, (YEAR). A copy of a letter dated 11/29/2017 from the facility to RI #134's estate executor acknowledged receipt of the record request and requested pre-payment for the records. A copy of a certified mail receipt d… | 2020-09-01 |
| 112 | 112 | KELLER LANDING | 15028 | 813 KELLER LANE | TUSCUMBIA | AL | 35674 | 2018-11-07 | 839 | F | 1 | 0 | 4G1T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, review of Employee Identifier (EI) #1's personnel file, the facility's policy titled HR225 Licensure and Certification of Personnel and information received from the Alabama Board of Nursing, the facility failed to ensure EI #1, a Registered Nurse (RN) maintained a current (active) nursing license. On 11/29/2017, the Alabama Board of Nursing suspended EI #1's nursing license. The Administrator stated in an interview, nursing licenses should be checked prior to hire and yearly. The last time the facility had verified (checked) the status of EI #1's nursing license was 1/6/2017. This deficient practice had the potential to affect all 79 residents who currently resided in the facility. Findings include: On 10/25/2018, the Alabama State Survey Agency received an anonymous complaint that indicated Employee Identifier (EI) #1, a Registered Nurse (RN) was working in the facility with a suspended nursing license. According to the anonymous caller, EI #1 worked the medication cart and was occasionally assigned the weekend supervisor's position. The facility's policy titled HR225 Licensure and Certification of Personnel effective 6/1/1996 with a review date of 6/1/2018, documented POLICY Genesis HealthCare and its subsidiaries, collectively Company, requires those employees whose jobs require specific licenses or certifications to maintain their credentials in compliance with state and federal laws at all times . The Term license is used throughout this document to include professional license, certification or other credentials that are required to perform the job duties. PURPOSE To assure that employees are properly licensed, certified, and/or registered to perform their duties. SCOPE Applies to all employees whose positions require licensed, certifications, or educations credentials. PR[NAME]ESS 1. At the time of employment, employees who require a license, certification, or registration must present verification of such. 2. A … | 2020-09-01 |
| 773 | 773 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-09-27 | 697 | G | 1 | 0 | CDXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, review of Resident Identifier (RI) #1's medical record, the emergency room (ER) record and a complaint received by the Alabama State Survey Agency, the facility failed to provide pain management to a resident experiencing pain. From 8/14/2018 to 8/15/2018, RI #1 was assessed as having a pain level of 9 on a scale of 0 to 10 (0 = no pain and 10 = worst pain). The ordered pain medication, [MEDICATION NAME], was not available in the facility for administration. When the medication did not arrive on 8/15/2018, RI #1 requested to be sent to the ER for pain relief. At the ER, RI #1 was administered pain medication and sent back to the facility. This deficient practice affected RI #1, one of three sampled residents reviewed for pain management. Findings include: RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include: [MEDICAL CONDITIONS], Pain in right knee and Chronic Pain. RI #1's physician's orders [REDACTED].#1 was ordered [MEDICATION NAME] Tablet 15 MG (milligram) Give 1 tablet by mouth every 6 hours related to [MEDICAL CONDITION] . Tylenol Extra Strength Tablet 500 MG Give 2 tablet by mouth every 4 hours as needed for Pain . Page 8 of Mosby's (YEAR) NURSING DRUG REFERENCE 30TH EDITION with a copyright date of (YEAR), indicated Tylenol is an nonopioid [MEDICATION NAME] used to treat mild to moderate pain or fever. Page 811, revealed [MEDICATION NAME] is an opioid [MEDICATION NAME] used to treat moderate to severe pain. RI #1's Medication Administration Record [REDACTED]. According to the MAR, RI #1 received two Tylenol Extra Strength tablets on 8/14/2018 at 12:48 AM for a complaint of pain. During an interview on 9/11/2018 at 2:23 PM, RI #1 stated he/she had run out of [MEDICATION NAME] on 8/14/2018. According to RI #1, the facility administered him/her Tylenol instead. RI #1 stated when the [MEDICATION NAME] wasn't available on 8/15/2018, he/she asked to be sent to the ER for some pain relief… | 2020-09-01 |
| 2146 | 2146 | OAK PARK | 15452 | 1365 GATEWOOD DRIVE | AUBURN | AL | 36830 | 2018-06-30 | 656 | D | 1 | 1 | BEZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, review of Resident Identifier (RI) #28's medical record and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #21, a Certified Nursing Assistant followed RI #28's care plan during the transfer of the resident from the wheelchair to the bed on 4/21/2018. EI #21 did not use the sit to stand (sit/stand or stand up) lift, as care planned. During the transfer, the resident's leg hit against the bed and caused a bruise. This affected RI #28, one of three sampled residents reviewed for accidents. Findings include: The facility's policy titled Comprehensive Care Plan for Long Term Care with a revised date of (MONTH) (YEAR), documented PURPOSE: The facility shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . RI #28 was admitted to the facility on [DATE]. RI #28's Quarterly Minimum Data Set with an assessment reference date of 2/28/2018 indicated the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14. RI #28 was assessed as extensive assistance of one person for transfers. RI #28's care plan titled Resident is at risk for injuries . with a problem onset date of 1/11/2017 and last reviewed (MONTH) (YEAR), had an approach of . staff to use sit to stand lift . The undated OAK PARK RESIDENT PROFILE for RI #28 indicated the resident required one-person assist for transfers and utilized the sit/stand lift. Contained within the facility's investigation was a typed statement written by the facility's Administrator, EI #1, dated 4/24/2018, which read . On 4/22/2018 (RI #28) a resident of Oak Park nursing home, told (his/her) nurse (EI #13) LPN, (his/her) CNA on 4/21/2018 did not use lift resulting in hurting (RI #28… | 2020-09-01 |
| 176 | 176 | DIVERSICARE OF MONTGOMERY | 15040 | 2020 NORTH COUNTRY CLUB DRIVE | MONTGOMERY | AL | 36106 | 2017-11-18 | 166 | D | 1 | 0 | 2LC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, review of the facility policy titled Customer Concern (Grievance)Policy, and the facility grievance log, the facility failed the ensure a grievance reported by Resident Identifier (RI) #4's family was investigated and findings communicated to the resident and family. This affected RI #4 one of four residents sampled for grievance concerns. Findings Include: A review of the facility policy titled Customer Concern (Grievance)Policy with an effective date of 11/28/2016 documented the following: . PR[NAME]ESS . Customer concerns will have a prompt response. The customer will be assured the concern will be investigated fully, and follow up communication will occur within 48 hours. RI #4 was admitted to the facility on [DATE]. Review of the facility grievances revealed a form titled COMPLAINT/CONCERN/GRIEVANCE/REQUEST FORM dated 10/11/2017 for RI #4. The grievance documented the following: . Alledges (alleges) (1) Not Being put back to bed in a timely manner 2) Poor customer svc (service) :Particular STAFF 3) Nurse left nebulizer on/running for 2.5 hrs (hours) -4)Medication not Being given in a timely manner 5)Missing a pair of Lounge pants and 5 Tshirts 6) Bed not Being put back down after care is given - . Please list two things we can do for you immediately to satisfy this . grievance . 1. Apology given 2. Inservice staff . Several areas on the form were not completed and were left blank. Those areas included whether the complainant was satisfied or not, whether the grievance was resolved with a description of the results, the date completed, and date of notification. An inservice dated 11/1/2017 provided with the grievance documented SUBJECTS COVERED: Nebulizer is to be turned off after each use, medication is to be given in timely manner, Bed is to (be) lowered back down after care is given. The inservice was not provided until three weeks after the grievance was voiced and was provided for seven nurses. On 11/18/2017 at … | 2020-09-01 |
| 2088 | 2088 | ORCHARD REHABILITATION & HEALTHCARE CENTER | 15442 | 629 STATE HIGHWAY 21 SOUTH | HAYNEVILLE | AL | 36040 | 2018-03-16 | 609 | D | 1 | 1 | BCZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, review of the facility's policy with a subject of Abuse, Neglect, and Exploitation, a report submitted to the Alabama State Survey Agency and Resident Identifier (RI) #1's medical record, the facility failed to timely report an allegation of neglect to the Alabama State Survey Agency. This deficient practice affected RI #215, one of 21 sampled residents and involved one of five reportable allegations of abuse and/or neglect. Findings include: The facility's policy titled, BALL HEALTHCARE SERVICES INC. ADMINISTRATIVE POLICY with a subject of Abuse, Neglect, and Exploitation, revised (MONTH) (YEAR), revealed: . PR[NAME]EDURE: In response to alleged or suspected incidents involving abuse, neglect . the Facility will take the following steps: . 3. If determined to be reportable, the event will be reported to the Alabama Department of Public Health, Division of Health Care Facilities (DHCF) via the Online Incident Reporting System for Nursing Homes within two (2) hours of the incident if the event involves abuse or results in serious bodily injury, or not later than twenty-four (24) hours if the event does not involve abuse or serious bodily injury . RI #215 was admitted to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. On [DATE] at 12:21 PM, the facility submitted to the Alabama State Survey Agency (Alabama Department of Public Health, DHCF) an allegation of neglect. According to the report, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform Cardiopulmonary Resuscitation (CPR) on RI #215, a resident with Full Code status, who was found unresponsive on [DATE] at 5:45 AM. Refer to F 678. During an interview on [DATE] at 9:50 AM, EI #1, the Administrator was asked what date did the failure of a licensed staff member to initiate CPR on RI #215, a resident with Full Code status, occur. EI #1 said, [DATE]. When asked when the incident should have been reported to the Alabama State Survey Agency… | 2020-09-01 |
| 2343 | 2343 | FATHER PURCELL MEMORIAL EXCEPTIONAL CHILDREN'S CTR | 01A193 | 2048 W FAIRVIEW AVE | MONTGOMERY | AL | 36108 | 2019-12-14 | 835 | J | 1 | 1 | N7DQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and Review of the POS [REDACTED]{EI} #1, FATHER PURCELL MEMORIAL MEDICATION GASTROSTOMY CHECK OFF and Father Purcell Memorial In-Service Education Program, the facility's Administrator, responsible for directing all aspects of the facility, and the Director of Nursing (DON), responsible for the overall function of the nursing department, failed to ensure a thorough investigation was conducted after becoming aware that Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) had administered the wrong medications to Resident Identifier (RI) #14 and RI #43 on 10/29/2019. The administrative staff further failed to implement measures to ensure no other resident received the wrong medication after becoming aware RI #43 had been administered medications ordered for another resident, RI #14. During the 7:00 AM to 3:00 PM shift on 10/29/2019, EI #1, the LPN prepared medications for RI #14, who resided in the room next to RI #43. As she entered the room to administer the medications, she noticed RI #14 was not in the room; the resident was in the shower room. The LPN placed the unlabeled cup of medications in the top drawer of the medication cart. The LPN then proceeded to prepare RI #43's medications for administration. As the LPN entered RI #43's room, she noticed the resident was not in the room; the resident was in the shower room. The LPN then walked to the medication cart and placed another unlabeled cup of medications in the top drawer of the medication cart. When both residents were available, the LPN got the medication cups from the top drawer and administered them to each of the residents. RI #43 then left the facility via ambulance transport for a planned procedure at the hospital. When RI #43 arrived in the emergency room , the resident was noted to have a slow heart rate, slow breathing, and a low blood pressure. The resident was difficult to arouse with no spontaneous movement even to pain or sternal rub. RI #4… | 2020-09-01 |
| 2359 | 2359 | CANTERBURY HEALTH CARE FACILITY | 15382 | 1720 KNOWLES ROAD | PHENIX CITY | AL | 36869 | 2017-04-13 | 241 | D | 1 | 0 | TRO911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and a record review of a policy entitled, Rights of Nursing Facility Residents, the facility failed to ensure a resident was treated with dignity and provided a shower as scheduled. This affected RI (Resident Identifier) #31, one of thirty-one sampled residents. Findings include: A review of a facility policy dated (MONTH) 1, 2012, titled, Rights of Nursing Facility Residents, revealed, By law every nursing facility resident has the right . To be treated with dignity, respect, courtesy and consideration without regard to race, religion, national origin, sex, age, disability, marital status or source of payment. To make their own choices regarding personal affairs, care,benefits and services. .To complain about care or treatment and receive prompt response to resolve the complaint without fear of reprisal or discrimination by the person providing services; to organize or participate in any program that presents residents' concerns to the facility administrator. A review of RI #31's current medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #31's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 2/02/17, revealed RI #31 had a BIMS (Brief Interview Mental Status) score of 15 out of a possible 15. This indicated RI #31 was cognitively intact for daily decision making . RI #31 was coded as totally dependent on staff for all transfers. RI #31 required extensive assistance with toileting and bathing and required physical help with the bathing activity. Range of motion was impaired on both sides. On 4/12/27 at 2:27 p.m., an interview was conducted with EI (Employee Identifier) #4, a CNA (Certified Nursing Assistant). EI #4 was asked when was RI #31 scheduled for a shower. EI #4 stated, I think Monday, Wednesday, and Friday. EI #4 was asked when was it put in place for RI #31 to receive a shower on the 1st shift. EI #4 stated, I don't kno… | 2020-08-01 |
| 1150 | 1150 | DIVERSICARE OF PELL CITY | 15189 | 510 WOLF CREEK ROAD, NORTH | PELL CITY | AL | 35125 | 2017-11-07 | 314 | E | 1 | 0 | DRM411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and medical record review, the facility failed to ensure Resident Identifier (RI) #1's wounds were treated by licensed staff in a manner to prevent worsening of RI #1's wounds on 07/28/17, 07/29/17 and 07/30/17. This occurred on three of three days that RI #1 resided in the facility. This affected RI #1, one of three residents whose wound care orders were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #1's medical record revealed no evidence of treatment being provided to RI #1's wounds which were present on RI #1's admission to the facility. Review of RI #1's Treatment Administration Record (TAR) for (MONTH) (YEAR) documented the following statement: No site of administration data found for TREATMENT ADMINISTRATION RECORD On 11/06/17 at 1:18 p.m., an interview was conducted with EI (Employee Identifier)#3, Licensed Practical Nurse (LPN). EI #3 was asked, did she perform RI #1's admission assessment on 07/28/17. EI #3 answered, yes. EI #3 was asked to look under the skin section and tell the surveyor what was documented on admission. EI #3 said, diabetes, 1, 2, 3 amputated toes on right foot, total of ten staples on abdomen in four separate surgical sites, right iliac crest (front) open area with drainage, left iliac crest (front) open area, area to bottom of right foot, and abrasion to right knee. The surveyor asked EI #3, did she find any evidence of treatments to those areas in RI #1's chart. EI #3 replied, No. It says no order data found for treatment administration record. On 11/06/17 at 3:20 p.m., an interview was conducted with EI #4, LPN. EI #4 was asked, do she see any evidence of a treatment on RI #1's TAR. EI #4 replied, no. On 11/07/17 at 11:08 a.m., an interview was conducted with EI #1, Registered Nurse/Director of Nursing. EI #1 was asked, were there any evidence for wound treatments for RI #1 during his/her stay. EI #1 said, she did not see… | 2020-09-01 |
| 1149 | 1149 | DIVERSICARE OF PELL CITY | 15189 | 510 WOLF CREEK ROAD, NORTH | PELL CITY | AL | 35125 | 2017-11-07 | 281 | E | 1 | 0 | DRM411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and medical record review, the facility failed to ensure a licensed nurse obtained an order to treat Resident Identifier (RI) #1's right foot wound and a wound on RI #1's left lower quadrant wound on the abdomen before providing treatment to those two areas. The facility further failed to provide evidence a surgical wound to RI #3's left fourth toe was treated on 11/02/17, 11/03/17 and 11/04/17. This affected RI #1 and RI #3, two of three sampled residents whose wound treatments were reviewed. Findings Include: 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #1's Treatment Administration Record (TAR) for (MONTH) (YEAR) documented the following statement: No site of administration data found for TREATMENT ADMINISTRATION RECORD Review of RI #1's Medication Administration Record [REDACTED]. Review of RI #1's Progress Notes revealed the following on 07/29/17 at 2:33 p.m., signed by Employee Identifier (EI) #4, LPN (Licensed Practical Nurse): Wound to bottom of right foot cleaned with wound cleanser and dressing applied.Wound to LLQ (left lower quadrant) cleaned with wound cleanser and covered with dressing. On 11/06/17 at 3:20 p.m., an interview was conducted with EI #4. The surveyor asked EI #4, how did she become aware of RI #1's open areas. EI #4 said, RI #1's family showed her the dressing on RI #1's foot and asked her when they were going to be changed. EI #4 said she remembered taking the wound cleanser and cleaning it and covering it with a dressing like what was on it. EI #4 was asked, did she write an order for [REDACTED].#4 was asked, did the family mention the areas on the abdomen, back and left and right iliac crests to her. EI #4 responded, the abdomen and the foot were all that she remembered. EI #4 said she cleaned the abdomen with wound cleanser also. EI #4 was asked, if she was supposed to have a physician's orders [REDACTED].#4 said, yes. EI #4 was asked, did she see … | 2020-09-01 |
| 1148 | 1148 | DIVERSICARE OF PELL CITY | 15189 | 510 WOLF CREEK ROAD, NORTH | PELL CITY | AL | 35125 | 2017-11-07 | 271 | D | 1 | 0 | DRM411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and medical record review, the facility failed to ensure admission physician's orders were obtained for the immediate care and treatment of [REDACTED].#1's wounds on 07/28/17. This affected RI #1, one of three residents whose physician's orders were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of RI #1's Clinical Health Status Evaluation 1.0 - V2 with an effective date of 07/28/2017, documented: .1. Admitting Information 1. Evaluation Type 1. Admission .12. Skin Condition .has toes 1,2,3 amputated on right foot, ulcer to right foot 5. Skin issues: location and description Site Description 14) Abdomen staples to abdomen intact, 4 separate surgical sites on abdomen consist of total of 10 staples. 19) Right iliac crest (front) open area with drainage 20) Left iliac crest (front) open area. Review of RI #1's Order Review Report with an admission date of [DATE], revealed there were no orders for treatments for the identified skin areas noted on the report. Review of RI #1's Medication Administration Record [REDACTED]. Review of RI #1's TREATMENT ADMINISTRATION RECORD, dated 07/1/2017 through 07/31/2017, documented: No site of administration data found for TREATMENT ADMINISTRATION RECORD. On 11/06/17 at 1:18 p.m., an interview was conducted with EI (Employee Identifier)#3, LPN (Licensed Practical Nurse). EI #3 was asked, did she perform RI #1's admission assessment on 07/28/17. EI #3 answered, yes. EI #3 was asked to look under the skin section and tell the surveyor what was documented on admission. EI #3 said, diabetes, 1, 2, 3 amputated toes on right foot, total of ten staples on abdomen in four separate surgical sites, right iliac crest (front) open area with drainage, left iliac crest (front) open area, area to bottom of right foot, and abrasion to right knee. EI #3 was asked, did she put the admission orders [REDACTED]. The surveyor asked EI #3, after having s… | 2020-09-01 |
| 3569 | 3569 | ALBERTVILLE NURSING HOME | 15163 | 750 ALABAMA HIGHWAY 75 NORTH | ALBERTVILLE | AL | 35950 | 2016-02-25 | 157 | D | 1 | 0 | 1SUS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, and review of a facility policy titled Change in a Resident's Condition or Status, the facility failed to notify the sponsor/family and physician of when RI #1 gained 10 punds in five days. On 1/19/2016, RI #1 weighed 145 lb and on 1/23/2016 weighed 155 pounds. This affected RI #1, one of three sampled residents. Findings include: A review of a facility policy titled, Change in a Resident's Condition or Status (no dated) documented: Policy Statement Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status . 1. The Nurse will notify the resident's attending physician when: . b. There is a significant change in the resident's physical, mental or psychosocial status; c. There is a need to alter the resident's treatment significantly . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed a form titled Extended Care Facility Transfer dated 18 (MONTH) (YEAR) documented . Outpatient Medications - chlorothiazide (chlorothiazide 500 mg (milligrams) oral tablet) 500 mg = 1 tab(s) (tablet) - Oral - Every AM (morning) PRN (as needed) (other (see comment) Please monitor daily weights and give dose if increase of 3 pounds in 24 hours, otherwise please hold chlorothiazide . A review of RI #1's (MONTH) (YEAR) Medication Administration Administration Record (MAR) DAILY WEIGHTS: January 19 - 145 January 20 - 148 January 21 - 150 January 22 - 152 January 23 - 155 On 2/23/2016 at 7:25 p.m. the surveyor conducted an phone interview with the complainant. The surveyor asked the complainant if they wanted to be informed by the facility if there was a changed in RI #1's condition. The complainant said yes as well as RI #1's first contact (sponsor). They wanted to be notified if there were any changes in RI #1's condition, especially weight gained. On 2/24/2016… | 2019-02-01 |
| 2825 | 2825 | BLUE RIDGE HEALTHCARE MONTGOMERY | 15228 | 4490 VIRGINIA LOOP ROAD | MONTGOMERY | AL | 36116 | 2016-10-13 | 514 | D | 1 | 0 | UBET11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Employee Identifier (EI) #4, a Registered Nurse (RN), accurately transcribed Resident Identifier (RI) #1's physician's orders [REDACTED]. Findings include: Documentation from POTTER PERRY . FUNDAMENTALS OF NURSING EIGHTH EDITION . CHAPTER 31 Medication Administration pages 611 and 612 . SAFETY GUIDELINES FOR NURSING SKILLS . Clarify all unclear orders and ask for help whenever you are uncertain about a medication order . ASSESSMENT 1. Check accuracy and completeness of each Medication Administration Record [REDACTED]. Documentation from POTTER PERRY . FUNDAMENTALS OF NURSING EIGHTH EDITION .Chapter 31 Medication administration page 584 . Standards . Professional standards such as Nursing: Scope and Standards of Practice . Many medication errors can be linked, in some way, to an inconsistency in adhering to these six rights: 1.medication 2.dose 3.patient 4.route 5.time. 6.documentation . RI #1 was admitted to the facility on [DATE]. A review of two documents faxed from a local hospital dated 9/30/2016 titled Discharge Medication Reconciliation Order Report did not include RI #1's name but were faxed along with RI #1's Discharge Orders. The transcribing nurse, identified as EI #4 (RN) transcribed the orders to RI #1's Medication Administration Record [REDACTED] An interview was conducted with EI #3, Director of Nursing (DON) on 10/12/2016 at 12:00 p.m. EI #3 was asked who was responsible for transcribing RI #1's orders on 9/30/2016. She replied, EI #4 RN. EI #3 was asked to review the faxed physician's orders [REDACTED].#1's. She replied, no they were not. An interview was conducted with EI #4, RN on 10/12/16 at 3:52 p.m. She was asked who was responsible for transcribing admission orders [REDACTED]. EI #4 replied, she did. EI #4 was asked if RI #1's physician orders [REDACTED]. This deficiency was cited as a result of the investigation of complaint/report number AL 733. | 2019-10-01 |
| 3504 | 3504 | VILLAGE AT COOK SPRINGS SKILLED NURSING FACILITY | 15195 | 415 COOK SPRINGS | PELL CITY | AL | 35125 | 2016-03-10 | 205 | D | 1 | 0 | DU6R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #1 was offered a notice of bed hold on 2/7/2016. On 2/7/2016 at 7:10 PM, RI #1 was taken to the local Sheriff's Department. The resident was released the following morning. Upon RI #1's return to the facility, on 2/8/2016 at 12:30 PM, the resident and sponsor were informed that RI #1 had been discharged and there was no available bed in the facility. This deficient practice affected RI #1, one of six closed records reviewed. The facility also failed to ensure the resident and/or sponsor were provided written information regarding bed hold. Findings include: On 3/4/2016, the State Agency received a complaint which indicated Village at Cook Springs Skilled Nursing Facility, discharged RI #1 on 2/7/2016 and would not readmit the resident on 2/8/2016. Page 22 of the VILLAGE AT COOK SPRINGS, LLC SKILLED NURSING FACILITY ADMISSION AGREEMENT dated (MONTH) 2007, documented NOTICE OF HOSPITAL TRANSFER AND BED HOLD AUTHORIZATION . You or your Sponsor may request the Facility to hold a bed open for you while you are absent from the Facility for temporary, medically necessary stays in a hospital or other facility . RI #1 was originally admitted to the facility on [DATE]. The Quarterly Minimum Data Set with an assessment reference date of 1/20/2016 indicated there was no active discharge plan in place for RI #1 to return to the community. RI #1's DISCHARGE SUMMARY completed by Employee Identifier (EI) #1, a Registered Nurse (RN) dated 2/7/2016, indicated RI #1 was discharged from the facility on 2/7/2016 at 7:10 PM. In an interview with RI #1's daughter on 3/8/2016 at 6:13 PM, she stated on Monday, 2/8/2016 at 12:30 PM, she arrived at the nursing facility and was informed by EI #1 that RI #1's belongings had been packed up and his/her bed had been given to someone else, less than 24 hours after RI #1 was discharged . In an interview on 3/9/2016 at 4:15 PM, EI #… | 2019-03-01 |
| 3278 | 3278 | GLENWOOD CENTER | 15147 | 211 ANA DRIVE | FLORENCE | AL | 35630 | 2016-05-12 | 281 | D | 1 | 0 | 82LF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #1's Physician order [REDACTED]. This affected RI #1, one of four sampled residents. Finding Include: A review of Potter and Perry, Fundamentals of Nursing, Eighth Edition, with a copyright date of 2013, page 305, documented: Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's admission physician's orders [REDACTED]. . PT, OT to eval (evaluate) & (and) Tx. (treat) as indicated . On 05/10/16 at 9:49 a.m., the surveyor conducted a phone interview with the family of RI #1. The family member said RI #1 was at the facility for Rehabilitation. The family member said they felt RI #1 just laid in bed while at the facility. The family member also said RI #1 had orders for PT and never received therapy. On 05/12/16 at 9:57 a.m., the surveyor conducted an interview with Employee Identifier (EI) #5, the Rehabilitation Director. The surveyor asked EI #5, when RI #1 was first admitted to the facility in (MONTH) (YEAR), who decided RI #1 did not need rehab services. EI #5 said her department was never given the orders for RI #1 to be evaluated so they did not evaluate RI #1. EI #5 said she could not say it was decided RI #1 did not need the service. EI #5 said the order for the PT and OT evaluation was not given to her department. On 05/12/16 at 10:53 a.m., the surveyor conducted a phone interview with EI #2, the Registered Nurse Unit Manager of the unit RI #1 resided on. The surveyor shared with EI #2 that on 03/03/16, the surveyor saw where RI #1 had orders for OT and PT to evaluate. The surveyor asked EI #2 did the evaluation occur. EI #2 said she was not sure if the evaluation occurred… | 2019-05-01 |
| 2718 | 2718 | MOBILE NURSING AND REHABILITATION CENTER | 15379 | 7020 BRUNS DRIVE | MOBILE | AL | 36695 | 2016-11-03 | 309 | D | 1 | 0 | 426711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #1's cardiac pacemaker was checked for a full year during the resident's stay at the facility. This affected one of three residents sampled for pacemakers. Findings Include: RI #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Annual MDS (Minimum Data Set), with an Assessment Reference Date (ARD) of 06/07/16, revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points. This score indicated RI #1 was cognitively intact. Under Section I - of the MDS, titled, Active Diagnoses, RI #1 was not assessed for having a cardiac pacemaker. A review of RI #1's care plans revealed RI #1 did not have a care plan for the pacemaker. A review of RI #1's Medical Record revealed no documentation the resident's cardiac pacemaker was checked in the past year. On 11/01/16 at 8:30 a.m., the surveyor interviewed RI #1's daughter. She said RI #1 had been a resident of the facility for three years, and the first two years the resident's pacemaker was checked. She said then all of a sudden it was not checked for a whole year. RI #1's daughter said the pacemaker was replaced at a local hospital on approximately 10/21/16. On 11/2/16 at 3:10 p.m., an interview was conducted with EI #4, the facility's (DON) Director of Nursing. The surveyor asked EI #4 who was responsible for obtaining orders for residents with a pacemaker. EI #4 stated, The Unit Manager, however we do not get orders for pacemakers. We set up appointments. The surveyor asked how nursing staff knew resident's pacemakers needed to be checked. EI #4 stated, We know if a resident has a pacemaker, it has to be checked. We usually get a follow up appointment for the pacemaker to be checked. EI #4 was asked were orders obtained for RI #1's pacemaker to be checked. EI #4 said other residents' pacemakers were checked… | 2019-11-01 |
| 3095 | 3095 | DIVERSICARE OF BESSEMER | 15209 | 820 GOLF COURSE ROAD | BESSEMER | AL | 35020 | 2016-07-14 | 323 | G | 1 | 0 | ZW0R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #1, a resident with left-sided weakness was not left unattended by Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) on 6/3/2016 during a transfer from the bed to the wheelchair. Employee Identifier (EI) #5 did not maintain her hands on RI #1 while providing care; EI #5 turned her back to reach for RI #1's wheelchair. RI #1 fell off the bed onto the floor and sustained a scalp laceration, that required six staples to close. This affected RI #1, one of three sample residents reviewed for falls. Finding include: RI #1 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #1's CLINICAL HEALTH STATUS admission note dated 4/23/2016 7:00 PM, indicated RI #1 had left-sided weakness. RI #1's Admission History and Physical ADMISSION NOTE dated 4/25/2016 3:24 PM, indicated RI #1 was a high fall risk. RI #1's care plan initiated on 4/26/2016 revealed, the resident was at risk for falls related to left sided weakness. RI #1's Minimum Data Set, with an assessment reference date of 6/21/2016, revealed RI #1 was assessed as requiring extensive assistance with bed mobility, dressing and personal hygiene. The GOLDEN LIVING- MEADOWOOD physician progress notes [REDACTED].#1 was a high fall risk. RI #1's VERIFICATION OF INVESTIGATION indicated on 6/3/2016 at 6:00 AM, a Certified Nursing Assistant (CNA) was giving RI #1 morning care prior to getting RI #1 up. RI #1 was sitting on the side of the bed, the CNA turned to get RI #1's wheelchair and RI #1 fell off the left side of the bed onto the floor. RI #1 was assessed and noted to have a three inch laceration to the left scalp and a large knot over the left eye. The report indicated RI #1 has left sided weakness from a previous stroke. The physician was called and the nursing home received orders to send RI #1 to a local hospital for further evaluation. According to the report, t… | 2019-07-01 |
| 996 | 996 | WESLEY PLACE ON HONEYSUCKLE | 15175 | 718 HONEYSUCKLE ROAD | DOTHAN | AL | 36305 | 2017-07-27 | 278 | D | 1 | 1 | HGI511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #10's 01/25/17, Annual Minimum Data Set (MDS) assessment accurately assessed RI #10's height of 65 inches. This deficient practice affected RI #10, one of 23 sampled residents whose MDS's were reviewed. Findings Include: RI #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #10's Admission Evaluation and Interim Care Plan, dated 01/22/16, documented: . Height: 65 in (inches . RI #10's Admission MDS assessment, with an Assessment Reference Date (ARD) of 01/29/16, also identified RI #10's height to be 65 inches. A review of RI #10's Annual MDS assessment, with an ARD of 01/25/17, identified RI #10's height to be 61 inches. On 07/27/17 at 1:12 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Registered Nurse (RN) Clinical Coordinator on the unit RI #10 resided on. The surveyor asked EI #2, on RI #10's 01/25/17 Annual MDS assessment, what was the resident's height. EI #2 said 61 inches. The surveyor asked EI #2, what was RI #10's height on the resident's 04/27/17 Quarterly MDS assessment. EI #2 said the height was 65 inches. The surveyor asked EI #2 would the 01/25/17 Annual MDS assessment be accurate. EI #2 replied, No that would not be accurate. On 07/27/17 at 1:58 p.m., the surveyor conducted an interview with EI #3, the RN MDS Mentor. The surveyor asked EI #3 was RI #10's Annual MDS assessment accurate, under height, if the admission MDS assessment was coded as 65 inches. EI #3 replied, No that's not right. | 2020-09-01 |
| 2346 | 2346 | MONTGOMERY CHILDREN'S SPECIALTY CENTER | 01A208 | 2853 FORBES DRIVE | MONTGOMERY | AL | 36110 | 2019-01-24 | 658 | E | 1 | 0 | WOYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #2's physician order, dated 10/01/18, for [MEDICATION NAME] 0.5 mg (milligram) to be administered every eight hours, was administered as ordered. RI #2's [MEDICATION NAME] was not started until 10/24/18, causing RI #2 to miss 22 days of the [MEDICATION NAME]. This deficient practice affected RI #2, one of seven sampled residents. Findings Include: RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #2's Clinic Notification Report dated 10/01/18, revealed: . Home Meds (medications) at Discharge Take These medications: [REDACTED] [MEDICATION NAME] Instructions: 0.5 milligrams(s) orally every 8 hours . RI #2's Progress Note dated 10/01/18 at 19:54 (7:54 p.m.) revealed: . Resident came back form (his/her) appt. (appointment) . [MEDICATION NAME] was prescribed 0.5 mg q (every) 8 hrs. (hours) . Electronically signed by Employee Identifier (EI) #3, the nurse assigned to care for RI #2 on 10/01/18. A review of RI #2's Outpatient Visit Summary, dated 10/22/18, revealed: . 5. Suppose to be on [MEDICATION NAME] 0.5milligrams every 8 hrs-not on facility medication list-please check on this . RI #2's Progress Note dated 10/23/18 at 16:11 (4:11 p.m.) revealed: . I have called (name of RI #2's physician) to follow-up on the [MEDICATION NAME] order for (RI #2) . This entry was electronically signed by EI #1, the Director of Nursing (DON). A review of RI #2's (MONTH) (YEAR) E-MAR (Electronic Medication Administration Record) revealed the [MEDICATION NAME] was not started until 10/24/18, 22 days after the order was prescribed. On 01/24/19 at 5:11 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 had RI #2 been administered the medication [MEDICATION NAME] while a resident at the facility. EI #1 said it looked like RI #2 was started on the [MEDICATION NAME] on 10/24/18. The surveyor asked EI #1 when s… | 2020-09-01 |
| 3353 | 3353 | ASPIRE PHYSICAL RECOVERY CENTER AT HOOVER, LLC | 15464 | 575 SOUTHLAND DRIVE | HOOVER | AL | 35226 | 2016-05-19 | 204 | D | 1 | 0 | QQYK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure a safe and orderly discharge for RI (Resident Identifier) #1 on 5/16/2016. This affected one of six residents sampled for transfer and discharge. Findings include: The facility's policy titled Discharge Procedure with an effective date of 11/10/2014 revealed the following . PURPOSE: The guest and family members are helped through the discharge process so any fears or worries are reduced . PR[NAME]ESS: I. Discharging Guest to Home . a) Guest orientation and planning for discharge are coordinated by the social service designee . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Date Set with an assessment reference date of 3/14/2016, identified the resident as being cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13. RI #1 was assessed as requiring extensive assistance with activities of daily living. RI #1 required a mechanically altered diet and received insulin injections. RI #1's Notice of Discharge for Non-Payment dated 4/14/2016 addressed to RI #1's sponsor documented . This correspondence shall serve as notice of the intent of Aspire Physical Recovery Center at Hoover, LLC to discharge (RI #1) to the custody of (RI #1's sponsor) at (address) on (MONTH) 16, (YEAR) . Please be advised that our Social Worker will be contacting you within the next several days to arrange for an appropriate discharge for (RI #1). A discharge plan will be provided to the resident, including a plan of care to meet his/her needs and to assist in adjustment . RI #1's social service progress note written by Employee Identifier (EI) #2, a Licensed Social Worker, dated 4/21/2016 8:02 PM, documented . SW spoke with daughter/sponsor at length about long term placement for (RI #1) . Daughter did state (RI #1) was not coming home with her . SW will continue to assist as indicated. RI #1's Discharge Summary indicated RI #1 wa… | 2019-05-01 |
| 3031 | 3031 | HILLVIEW TERRACE | 15436 | 100 PERRY HILL RD | MONTGOMERY | AL | 36109 | 2016-08-18 | 514 | D | 1 | 0 | IFCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure licensed staff documented provision of care, hospital communication regarding Intravenous (IV) access, and physician communication regarding Resident Identifier (RI) #1. This affected RI #1, one of four residents whose charts/nurses' notes were reviewed. Findings Include: A review of the facility's policy and procedure titled, Nursing Documentation Guidelines without a date, revealed the following: . It is the policy of this facility that nursing documentation will be done in an accurate and timely manner. Documentation is necessary to reflect the resident's overall condition in the medical record . Interpretation and Implementation Guidelines: . III. All residents . chart all exceptions on any resident; change in clinical status . physician contact . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RI #1's physician's orders [REDACTED].[MEDICATION NAME] IV x (times) 7 days . ( . signature of Employee Identifier #2/Registered Nurse/RN)) A review of RI #1's Nurse's Notes revealed the following: On 08/04/16, without a time, documented EI #3, (Registered Nurse/RN,) made two unsuccessful IV attempts. On 08/05/16 at 4:30 p.m., EI #4, (Licensed Practical Nurse/LPN), documented she was unable to get an IV started. On 08/17/16 at 10:55 a.m., during an interview with EI #4, she was asked who did she make aware she was unable to obtain IV access. EI #4 stated on 08/05/16 around 10:00 a.m., she attempted once and was unsuccessful and another nurse, who was training, attempted IV access and was unsuccessful. At that time, EI #4 stated she informed EI #2, (RN/Clinical Nurse Manager/CNM), who attempted to obtain IV access for RI #1 and was unsuccessful. EI #4 was provided a copy of RI #1's nurses's notes dated 08/05/16 at 4:30 p.m. for review. After EI #4 reviewed the nurses' notes, she stated after EI #2 was unsuccessful, she (EI #4) notified the … | 2019-08-01 |
| 3503 | 3503 | VILLAGE AT COOK SPRINGS SKILLED NURSING FACILITY | 15195 | 415 COOK SPRINGS | PELL CITY | AL | 35125 | 2016-03-10 | 204 | D | 1 | 0 | DU6R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to implement discharge planning for Resident Identifier (RI) #1. The facility failed to arrange for durable medical equipment, primary care physician follow-up, home health services; and to provide discharge instructions to the resident and sponsor to acquire all current medications, treatments and therapies required for Resident Identifier (RI) #1. In addition, the facility further failed to follow-up to ensure RI #1 was receiving the support services needed for the resident to reside at home. This affected RI #1, one of six closed records reviewed. Findings include: On 3/4/2016, the State Agency received a complaint which alleged Village at Cook Springs Skilled Nursing Facility, discharged RI #1 on 2/7/2016, without the knowledge of the resident's sponsor. The complainant further alleged RI #1 was sleeping on the sofa in his/her daughter's house because the facility made no arrangements for medical equipment. RI #1 was admitted to the facility 1/15/2014. The Quarterly Minimum Data Set (MDS), with an assessment reference date of 1/20/2016, identified RI #1 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. RI #1 was assessed as requiring supervision with bed mobility, locomotion on and off the unit, eating, and toilet use; limited assistance with bathing; and extensive assistance with dressing and personal hygiene. RI #1 was further assessed as having functional limitations on one side in the upper and lower extremities. RI #1 required the use of a wheelchair for mobility. During this assessment period, RI #1 was on a mechanically altered diet. RI #1's care plan titled (RI #1) has potential for skin breakdown related to impaired mobility, with a problem onset date of 1/15/2014, had an approach of * Pressure reduction mattress to bed . RI #1's care plan titled (RI #1) has potential for pain related to aging and disease process, with a problem on… | 2019-03-01 |
| 3502 | 3502 | VILLAGE AT COOK SPRINGS SKILLED NURSING FACILITY | 15195 | 415 COOK SPRINGS | PELL CITY | AL | 35125 | 2016-03-10 | 203 | D | 1 | 0 | DU6R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to issue Resident Identifier (RI) #1, a notice of discharge. On 2/7/2016, the facility discharged RI #1 from the facility and failed to issue a notice that included: a reason for transfer/discharge; a statement of the resident's right to appeal; the name, address and phone number of the State long term care Ombudsman and the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals. This deficient practice affected RI #1, one of six closed records reviewed. Findings include: On 3/4/2016, the State Agency received a complaint which alleged Village at Cook Springs Skilled Nursing Facility, discharged RI #1 from the facility on 2/7/2016, without the resident's sponsor's knowledge. According to the caller, when RI #1's sponsor came to the facility on [DATE], the facility only gave her the resident's Face Sheet, a list of medications the resident was ordered and a six-day supply of those meds. A FACE SHEET is a summary of information about a resident. RI #1's Face Sheet included, but was not not limited to: resident identification such as date of birth, room number and admitted ; medical information such as height, weight, diagnoses, the name of the primary and alternate facility's physicians; demographics such as marital status, primary language and race; billing information, and the name, address and phone number of the responsible party. The facility's policy titled Transfer and Discharge . with an original date of 2/1/2007 and effective date of 1/2016, documented . STANDARD Transfer means the moving of a resident from the facility to another legally responsible institutional setting. Discharge means the moving of a resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident's care . PR[NAME]ESS 1. All non emergency transfers or discharges should be coordinated by the Soc… | 2019-03-01 |
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CREATE TABLE [cms_AL] ( [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 );